Compositions Comprising Statins, Biguanides and Further Agents for Reducing Cardiometabolic Risk

ABSTRACT

Compositions and methods comprising at least one biguanide compound and at least one statin combined with at least one additional active agent in fixed dose combinations are provided for reducing cardiometabolic risk, and for the treatment of cardiovascular disease, wherein the biguanide compound is formulated for delayed release.

FIELD OF THE INVENTION

The present invention relates generally to reducing cardiometabolic riskin a comprehensive and concerted fashion in patients in need thereof; byadministering a fixed dose combination therapy comprising at least onebiguanide, at least one statin and at least one additional active agentin a unitary dosage form.

BACKGROUND OF THE INVENTION

Cardiovascular disease (CVD) generally includes coronary artery disease,cerebrovascular disease and peripheral arterial disease, and is themajor cause of morbidity and mortality in the Western world. (Brunzellet al. Lipoprotein Management in Patients with Cardiometabolic Risk,Diabetes Care 2008 31: 811-822). Notwithstanding significantimprovements in therapeutic options over the last few decades, theinitial presentation of coronary arterial disease in particularmanifests as sudden death in up to one-third of patients. Id.Accordingly, better and more effective intervention options are stillneeded to prevent atherosclerosis and/or reduce its rate of progressiononce the disease process is initiated.

To more effectively address this rapidly growing public health problemthe American Diabetes Association and the American College of CardiologyFoundation have jointly developed and advocated for the treatment ofcardiometabolic risk (CMR), which refers to a high lifetime risk of CVD.(Eckel et al. Preventing Cardiovascular Disease and Diabetes, DiabetesCare 2006 29:1697-1699). Notably, the risk factors for cardiovasculardisease and type 2 diabetes often cluster, including obesity, insulinresistance, hyperglycemia, dyslipoproteinemia and hypertension. Whenpatients have one or more of these risk factors and are physicallyinactive or smoke, their cardiometabolic risk increases even further.

Lipoprotein abnormalities, including elevated triglycerides, low HDLcholesterol, and increased LDL are common findings in patients with CMR.As such, administration of therapeutic agents directed at lowering LDLcholesterol such as, e.g., statins can reduce the risk of CVD events indiabetic patients, and in non-diabetic patients having other CVD riskfactors. Even with adequate cholesterol lowering, however, many patientson statin therapy still have significant CVD risk. (See Brunell, supra).Accordingly, more effective therapies are clearly still needed to betteraddress this multivariate and complex series of disorders.

The impact of certain hypoglycemic agents such as pioglitazone andglimepiride on atherosclerotic plaque formation in diabetic patients hasbeen evaluated. The PERISCOPE study compared pioglitazone withglimepiride in diabetics; atherosclerotic plaque volume was measured andfollowed over time. Nissen et al. Comparison of pioglitazone vsglimepiride on progression of coronary atherosclerosis in patients withtype 2 diabetes”. JAMA 2008 299 (13): 1561-73. Glimepiride therapy hadhighly significant progression of plaque volume over time of 0.73percent. In comparison, pioglitazone had a −0.16 percent regression inplaque volume. Notably, however, to date, no oral anti-diabetic drug hasbeen shown to reduce the risk of cardiovascular complications. Id.

Metformin is commonly prescribed for glycemic control in patients havingtype II diabetes, and has also been shown to improve serum lipids,decreasing triglycerides, free fatty acids, and LDL-cholesterol andmodestly increasing HDL-cholesterol. (Bailey & Turner Metformin. N EnglJ Med. 1996 Feb. 29; 334(9) Unfortunately, however, metformin alsoproduces significant gastrointestinal complications that have restrictedits use beyond diabetic patients per se, and it is furthercontraindicated in patients having hypoxic conditions caused by, e.g.respiratory or heart failure. Moreover, conventional dosing strategiesrequire a gradual dose escalation from 500 mg bid up to 1000 mg bid fora daily maximum dose of 2000 mg, with further uptitration to as much as3000 mg/day to achieve appropriate glycemic control, severely limitingthe ability of formulators to combine it with additional active agentsin fixed dose combination therapies. To date, it has proven difficult toeffectively combine metformin with multiple active agents in the samesingle-dose formulation.

Clearly then, there continues to be a need for more comprehensiveapproach to reducing cardiometabolic risk in general, and for treatingand/or preventing cardiovascular disease in particular.

SUMMARY OF THE INVENTION

The present invention provides more comprehensive and effectivecombination therapies for reducing cardiometabolic risk in patients inneed thereof, and for treating and/or preventing cardiovascular disease,employing at least one biguanide, at least one statin and at least oneadditional active agent. As demonstrated herein, biguanides such asmetformin can be administered with significantly reducedgastrointestinal complications using delayed release (DR) formulations,thereby enabling safe and effective administration of combinations ofbiguanides, statins and other active agents to a much broader patientpopulation in unitary pharmaceutical compositions. Moreover, andremarkably, even once-a-day dosing of biguanides can be done with fulltherapeutic efficacy at the reduced dosages described and claimedherein.

Suitable biguanides contemplated for use in the subject inventioninclude, e.g. metformin, phenformin, buformin and like compoundsdescribed herein. Suitable statins or HMG-CoA reductase inhibitors foruse in the subject invention include, e.g. lovastatin, atorvastatin,fluvastatin, rosuvastatin, simvastatin, pravastatin, pitavastatin, andthe like. Additional active agents contemplated for use in the subjectcompositions and methods include, e.g. anti-hypertensives andanti-platelet agents as well as diuretics, bile acid sequesterants,incretin enhancers and mimetics, oral anti-diabetic agents ,anti-obesity agents, and anti-atherosclerotics.

Suitable anti-hypertensives for use in the subject invention include,e.g., beta blockers (atenolol, betaxolol, metoprolol, nadolol,nebivolol, oxprenolol, pindolol, propranolol, timolol, etc.), alpha-1blockers (alfuzosin, arotinolol, doxazosin, indoramin, moxisylyte,phenoxybenzamine, phentolamine, prazosin, silodosin, tamsulosin,terazosin, tolazoline, trimazosin), alpha-2 agonists (apraclonidine,brimonidine, clonidine, guanabenz, guanfacine, lofexidine, tolonidine,mixed alpha/beta blockers (bucindolol, carvedilol, labetalol, etc.),calcium channel blockers such as dihydropyridines (amlodipine,felodipine, isradipine, lercanidipine, nicardipine, nifedipine,nimodipine, nitrendipine, etc.) and non-dihydropyridines (diltiazcm,vcrapamil, etc.), renin inhibitors (aliskircn), ACE inhibitors(captopril, enalapril, fosinopril, lisinopril, perindopril, quinapril,ramipril, trandolapril, benazepril, etc.), angiotensin II receptorantagonists (can desartan, eprosartan, irbesartan, losartan, olmesartan,telmisartan, valsartan, etc.), and the like.

Suitable anti-platelet medications for use in the subject inventioninclude, e.g., cyclooxygenase inhibitors (acetylsalicylic acid(aspirin), aloxiprin, carbasalate calcium, indobufen, trifusal, etc.),ADP receptor inhibitors (clopidogrel, ticlopidine, ticagrelor, etc.),phosphodiesterase inhibitors (cilostazol, etc.), adenose reuptakeinhibitors (dipyridamole, etc.), thromboxane synthase or receptorinhibitors (picotamide, ramatroban, terbogrel, etc.), anagrelide,prasugrel, cloricromen, and the like.

Suitable diuretics for use in the subject invention include e.g., loopdiuretics (bumetanide, cthacrynic acid, furoscmidc, torsemide, etc.),thiazide diuretics (cpitizidc, hydrochlorothiazide, chlorothiazide,bendroflumethiazide, etc.), thiazide-like diuretics (indapamide,chlorthalidone, metolazone, etc.), potassium-sparing diuretics(amiloride, triamterene, spironolactone, etc.), and the like.

Suitable bile acid sequesterants for use in the subject inventioninclude, e.g., cholestyramine, colesevelam, colestipol, and the like.

Suitable incretin mimetics and enhancers for use in the subjectinvention include, e.g., peptidic and non-peptidic GLP-1 mimetics(including, e.g., allosteric activators of the GLP-1 receptor), peptidicand non-peptidic PYY mimetics, peptidic and non-peptidic Ghrelinantagonists and the like.

Suitable oral anti-diabetic agents for use in combination with metforminin the subject compositions and methods include, e.g., sulfonylureas(glyburide, glimepiride, glipizide, gliclazide, glycopyramide,gliquidone, tolbutamide, acetohexamide, tolazamide, chlorpropamide,carbutamide, etc.), nonsulfonylureas (repaglinide, nateglinide, etc.),thiazolidinediones (rosiglitazone, pioglitazone, rivoglitazone,troglitazone, ciglitazone, darglitazone, netoglitazone, englitazone,etc.), dual PPAR agonists (e.g., aleglitazar, farglitazar, muraglitazar,tesaglitazar, telmisartan, and the like), dipeptidyl peptidase-4inhibitors (vildagliptin, sitagliptin, saxagliptin, linagliptin,allogliptin, septagliptin, berberine, etc.), sodium-glucoseco-transporter-1 or 2 (SGLT1 or 2) inhibitors (canagliflozin,empagliflozin, dapagliflozin, LX4211, etc.) meglitinides (nateglinide,repaglinide, etc.), alpha-glucosidase inhibitors (acarbose, miglitol,voglibose, etc.), agonists of GPR40, GPR120, GPR119, GPR41, GPR43, andthe like.

Suitable anti-obesity agents for use for use in the subject inventioninclude, e.g., Orlistat (Zenical), Lorcaserin (Belviq), Sibutramine(Meridia, withdrawn from most markets), Rimonabant (Acomplia), Exenatide(Byetta and Bydureon), Pramlintide (Symlin), Fen-Phen, Redux, ZGN-433,Phentermine/topiramate (Qsymia), Naltrexone/buproprion (Contrave), aswell as alternative medicine options including, e.g., conjugatedlinoleic acid, green tea extract, khat, lipoic acid, ECA Stack(Ephedrine Caffeine Stack), Raspberry ketone and the like.

Suitable anti-artherosclerotics for use in the subject invention includecompounds that can reduce atherosclerosis independent of changes inother risk factors, e.g. fish oil as well as inhibitors of proproteinconvertase subtilisin/kexin type 9 (PCSK9) such as AMG145 (Amgen),1D05-IgG2 (Merck & Co.), and SAR236553/REGN727 (Avcntis/Rcgcncron),peptides mimicking the LDLR that binds to PCSK9 (e.g. Shan et al. (2008)Biochem. Biophys. Res. Commun. 375: 69-73), and nucleic acidtherapeutics targeting PCSK9 (e.g Graham et al. (2007) J. Lipid Res.48:763-7; Lindholm et al. (2012) Mol. Ther. 20:376-81).

Also contemplated as additional active agents are HDL/LDL ratiomodifying compounds including, e.g., niacin, acipomox, MK-0354, othermodulators of GPR81, GPR109A, GPR109B and the like.

Accordingly, in one aspect, provided herein are fixed-dose combinationdosage forms for reducing cardiometabolic risk in a patient in needthereof, comprising at least one biguanide, at least one statin, and atleast one additional active agent selected from the group consisting ofanti-hypertensives, anti-platelet agents, diuretics, bile acidsequesterants, oral anti-diabetic agents, incretin mimetics andenhancers, anti-obesity agents, and anti-atherosclerotics. The subjectcombination dosage forms may comprise at least one additional activeagent, more preferably at least two additional active agents, morepreferably at least three additional active agents, more preferably atleast four or five additional active agents, wherein the metformin orother biguanide compound is formulated for delayed release. The statins,anti-hypertensives and additional active agents may be conventionallyformulated for immediate-release, extended release and/ordelayed-release in accordance with their respective established dosingprotocols. The combination dosage form can be a multi-layer tablet, or acapsule with the three or more components encapsulated inappropriately-formulated mini-tablets.

In preferred embodiments, the fixed dose combination dosage formcomprises at least one biguanide, at least one statin, at least oneanti-hypertensive, and optionally at least one anti-platelet agent. In aparticularly preferred embodiment of the combination dosage form thebiguanide comprises metformin and the anti-hypertensive comprises an ACEinhibitor or an angiotensin II receptor antagonist, and theanti-platelet agent comprises aspirin. In an exemplary embodiment, thesubject combination dosage form comprises from about 600-800 mg ofmetformin, from about 20-40 mg of simvastatin or atorvastatin, fromabout 20-25 mg of benazepril, lisinopril or losartan, and optionallyfrom about 75-90 mg of aspirin.

Preferably, the combination dosage form comprises less than about 950 or900 mg of metformin or other biguanide, more preferably less than about875 or 850 mg, and most preferably less than about 825 or 800 mg ofbiguanidc. In preferred embodiments, the combination dosage formcomprises from about 3 or 30 or 300 to about 9 or 90 or 900 mg ofmetformin or other biguanide, more preferably from about 4 or 40 or 400to about 8 or 80 or 800 mg of biguanide, most preferably from about 6 or60 or 600 to about 8 or 80 or 800 mg of biguanide. Suitable biguanidecompounds for use in the subject methods include, e.g., metformin,phenformin, buformin or imeglimin, including analogs, salts, solvates,polymorphs, hydrates, N-oxides, and prodrugs of such compounds.

The fixed-dose pharmaceutical compositions according to the presentteachings may be administered to a subject in need thereof to reducetheir cardiometabolic risk. Clinical conditions presenting an increasedcardiometabolic risk that may benefit from administration of the subjecttherapies include type II diabetes, familial combined hyperlipidemia,familial hypoalphalipoproteinemia, and polycystic ovary syndrome, aswell as preclinical conditions such as obesity, prediabetes andhyperglycemia in general. The methods and compositions disclosed hereinare particularly suitable for patients having a contraindication forbiguanide compounds, e.g., metformin, phenformin or buformin. Suchcontraindication may be a hypoxic condition, impaired lactate clearance,and/or impaired clearance of the biguanide compound, e.g., impairedmetformin clearance.

In another aspect, also provided herein are methods of treatingcardiovascular disease in a patient in need thereof, comprisingadministering a therapeutically effective amount of at least onebiguanide compound, at least one statin and at least one additionalactive agent to said patient in a fixed dose combination dosage form,wherein the at least one additional active agent selected from the groupconsisting of anti-hypertensives, anti-platelet agents, diuretics, bileacid sequesterants, oral anti-diabetic agents, incretin mimetics,anti-obesity agents, and anti-atherosclerotics. In preferredembodiments, the at least one additional active agent is ananti-hypertensive, e.g., an ACE inhibitor or an angiotensin II receptorantagonist. In particularly preferred embodiments, the fixed dosecombination dosage form further comprises an anti-platelet agent, e.g.,aspirin.

Advantageously, the metformin or other biguanide is formulated fordelayed release so as to minimize the systemic bioavailability of thebiguanide compound in the patient. In particular embodiments,administration of the subject delayed-release formulation minimizes themean plasma AUC, the mean plasma C_(max) and/or the circulating plasmaconcentration of the biguanide compound in the patient compared to anidentical protocol administering an IR or XR formulation having the sameamount of the biguanide compound. In preferred embodiments, thebiguanide compound is metformin, the IR composition is Glucophage® andthe XR composition is Glucophage® XR.

Administration of the subject dosage forms may be twice daily (b.i.d.),in the morning and evening, or once daily (omni in die, abbreviated as“OD”). In certain preferred embodiments, administration may be oncedaily in the morning, e.g., before 1 pm, preferably before 12 noon or 11am, more preferably before 10 or 9 am, or with the morning meal. Inother preferred embodiments, administration may be once daily in theevening, e.g., after 5 pm, more preferably after 6 pm or 7 pm, or withthe evening meal. In another preferred embodiment, administration may beonce daily at bedtime.

The subject methods administer therapeutically effective amounts of thebiguanide compound(s). Notably, however, the inventive methods providedherein advantageously allow for lower therapeutic doses than prior artformulations, both on a per unit basis and/or on a daily dose basis. Incertain embodiments of the methods disclosed herein, the biguanidecompound is administered twice daily in an oral dosage form at a perunit dose less than 1000 mg BID, e.g. 600, 700 or 800 mg BID. In certainpreferred embodiments of the methods disclosed herein, the twice dailyoral dosage is less than 500 mg BID, e.g., less than 400 mg BID, e.g.,less than 300 mg BID, e.g., about 150, 200 or 250 mg BID. In alternativepreferred embodiments, the biguanide compound is administered once a dayat a per unit dose of 75 mg OD, 125 mg OD, 250 mg OD, 300 mg OD, 500 mgOD, 600 mg OD, 650 mg OD, 700 mg OD, 750 mg OD, 800 mg OD. or 900 mg OD.In additional embodiments, the total daily dose (TDD) of the biguanidecompound is less than 2000 mg/day, preferably less than 1500 mg/day,more preferably less than 1000 or 750 mg/day, most preferably less than500, 400, 300, or 200 mg/day.

In any of the methods disclosed herein, the delayed-release formulationof the metformin or other biguanide may be enterically coated. In oneembodiment, the biguanide compound is targeted for delivery to the smallintestine, and the formulation comprises an oral dosage form entericallycoated at a pH at or above 5.0, 5.5, or 6.0, e.g., a pH 5.0 entericcoating, a pH 5.5 enteric coating, a pH 6.0 enteric coating, a pH 6.5enteric coating, or a pH 7.0 enteric coating, or combinations thereof.In another embodiment, the oral dosage form may further comprise anextended-release component for the biguanide compound. In preferredembodiments, the biguanide compound is targeted for delivery to thedistal small intestine, and the formulation comprises an oral dosageform enterically coated at a pH at or above 6.0 or 6.5.

In the compositions and methods disclosed herein, the biguanide compoundmay be or comprise metformin, a metformin salt, solvate, polymorph,hydrate, N-oxide or prodrug. In preferred embodiments, the biguanidecompound is a metformin salt selected from the group consisting ofhydrochloride, phosphate, sulfate, hydrobromide, salicylate, maleate,benzoate, succinnate, ethanesulfonatc, fumarate, glycolate, palmoatc,oratatc, acetate, isobutyratc, acetylsalicylate, nicotinic acid,adamantoate, zinc-chlorophylin, carboxylic acid, benzoic acid,dichloroacetic acid, theophylin-7-acetate, clofibrate, tartate, oxalate,tannate and hydroxyl acid. In a particularly preferred embodiment, thebiguanide compound is metformin hydrochloride.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 shows the design of the study described in Example 1.

FIG. 2 shows the events during the treatment period of the studydescribed in Example 1.

FIG. 3 shows the plasma concentration of metformin immediate-release(Metformin IR) () and metformin delayed-release (Metformin DR) (▪)(x-axis; ng/mL) as a function of time (y-axis; min) after ingestion att=−240 and after a meal at t=0 min.

FIG. 4A shows the plasma concentration of PYY (x-axis; pg/mL) as afunction of time (y-axis; min) in subjects at baseline (□, ∘) or afteringestion of either Metformin IR () or Metformin DR (▪) and after ameal at t=0 min. FIG.4B shows the plasma concentration of activeGLP-1(x-axis; GLP-1A pmol/L) as a function of time (y-axis; min) insubjects at baseline (□, ∘) or after ingestion of either Metformin IR() or Metformin DR (▪) and after a meal at t=0 min. FIG. 4C shows theplasma concentration of total GLP-1 (x-axis; GLP-1T pmol/L) as afunction of time (y-axis; min) in subjects at baseline (□, ∘) or afteringestion of either Metformin IR () or Metformin DR (▪) and after ameal at t=0 min. For FIGS. 4A-4C, percent increase in Abs AUC iscompared to baseline values.

FIG. 5A shows the plasma concentration of glucose (x-axis; mg/dL) as afunction of time (y-axis; min) in subjects at baseline (□, ∘) or afteringestion of either Metformin IR () or Metformin DR (▪) and after ameal at t=0 min. FIG. 5B shows the plasma concentration of insulin(x-axis; pmol/L) as a function of time (y-axis; min) in subjects atbaseline (≡, ∘) or after ingestion of either Metformin IR () orMetformin DR (▪) and after a meal at t=0 min. For FIGS. 5A-5B, percentdecrease in Abs AUC is compared to baseline values.

FIG. 6 is a graph that shows the area under the curve of PYY (x-axis;log transformed) as a function of the area under the curve of metformin(ng/mL*min) after ingestion of Metformin IR () and Metformin DR (▪).

FIG. 7A shows the plasma concentration of Metformin IR () and MetforminDR (▪) (x-axis; ng/mL) as a function of time (y-axis; min) afteringestion at t=−240 and after a meal at t=0 min. FIG. 7B shows theplasma concentration of PYY (x-axis; pg/mL) as a function of time(y-axis; min) in subjects at baseline (□, ∘) or after ingestion ofeither Metformin IR () or Metformin DR (▪) and after a meal at t=0 min.

FIG. 8 shows the mean plasma metformin concentrations (x-axis; ng/mL) atDay 5 of 500 mg (♦) and 1000 mg (▪) Metformin DR, 1000 mg Metformin IR(∘), and 500 mg Metformin IR+1000 mg Metformin DR (▴) as a function oftime (y-axis; min). Dose was administered at t=−1 minute.

FIG. 9 shows the steady-state relative bioavailability in subjects withtype 2 diabetes of 500 mg BID and 1000 mg BID of Metformin DR comparedto 1000 mg BID of Metformin IR based on the 11 hour plasma metformin AUCon Day 5 (y-axis; % AUC_((0-11hr))). These levels constitute a 45% and57% reduction in the overall plasma metformin extent of exposure for 500mg BID and 1000 mg BID of Metformin DR compared to 1000 mg BID ofMetformin IR.

FIG. 10 shows the mean plasma PYY total concentrations (x-axis; pg/mL)as a function of time (y-axis; min) in subjects at baseline (∘) or Day 5of the designated treatment ().

FIG. 11 shows the mean plasma GLP-1 active concentration (x-axis;pmol/L) as a function of time (y-axis; min) in subjects at baseline (∘)or Day 5 of the designated treatment (. Breakfast was administered att=0 min, dose was administered at t=−1 minute, and lunch wasadministered at t=300 min.

FIG. 12 shows the mean plasma glucose concentration (x-axis; mg/dL) as afunction of time (y-axis; min) in subjects at baseline (∘) or Day 5 ofthe designated treatment ().

FIG. 13 shows the individual change in fasting plasma glucoseconcentrations (x-axis; mg/dL) as a function of time (y-axis; min) frombaseline to Day 5 by scatterplot in subjects treated with 500 mg (♦) and1000 mg (▪) Metformin DR, 1000 mg Metformin IR () , and 500 mgMetformin IR+1000 mg Metformin DR (▴)(y-axis) The line in the panelmarks the LS Mean Change in glucose (mg/dL) for each treatment.

FIG. 14 shows the mean plasma metformin concentration (x-axis; ng/mL) of500 mg (♦) and 1000 mg (▪) Metformin DR, 1000 mg Metformin IR (∘), and2000 mg metformin extended release (Metformin XR) a function of time(y-axis; hours). Dose was administered at t=0 hours. Second dose wasadministered for BID regimens at t=12 hours. Meals/snacks were providedat t=−0.42, 2.08, 11.5, 18 and 24 hours.

FIG. 15 shows the C_(max) (left panel) and AUC₀₋₃₆ (right panel) of oneday's dosing of 1000 mg BID metformin IR, 500 mg BID and 1000 mg BID ofMetformin DR and 2000 mg QD metformin XR. The * signifies astatistically significant reduction in exposure compared to bothmetformin IR and metformin XR (all p<0.0001)

FIG. 16 shows the relative bioavailability of one day's dosing of 500and 1000 mg BID Metformin DR compared to 1000 mg BID Metformin IR (leftpanel) and the relative bioavailability of one day's dosing of 500 and1000 mg BID Metformin DR compared to 2000 mg QD Metformin XR (rightpanel)

FIG. 17 shows the plasma AUC level (left panel) and change in fastingglucose (right panel) of 1000 mg QD AM, 1000 mg QD PM and 500 mg BIDmetformin DR.

DETAILED DESCRIPTION

Contemplated herein are methods and compositions for reducingcardiometabolic risk in individuals in need thereof, and for treatingand/or preventing cardiovascular disease as described herein, usingfixed-dose combination therapies comprising at least one biguanide, atleast one statin and at least one additional active agent. The at leastone additional active agent is advantageously selected from amonganti-hypertensives, anti-platelet agents, diuretics, bile acidsequesterants, incretin mimetics and enhancers, oral anti-diabeticagents, anti-obesity agents, and anti-artherosclerotics. Preferably, thesubject compositions and methods employ at least one biguanide, e.g.,metformin, at least one statin, and at least one anti-hypertensive,e.g., an ACE inhibitor or angiotensin II antagonist, and may optionallyfurther include at least one anti-platelet agent.

Advantageously, as demonstrated herein full therapeutic efficacy ofmetformin may be obtained using delayed-release formulations with lowerdosages when administered either once- or twice-daily, thereby enablingmore comprehensive combinations of metformin with additional activeagents in unitary dosage forms. Moreover, the subject methods andcompositions also significantly improve GI tolerability and reduce thepossibility of adverse effects such as lactic acidosis, thereby enablingtheir safe and effective use in a much broader class of patientsincluding those suffering or at risk of cardiovascular disease.

Accordingly, provided herein are fixed-dose pharmaceutical compositionsfor reducing cardiometabolic risk and treating or preventingcardiovascular disease, combining metformin or another biguanidecompound formulated for DR with at least one statin and at least oneadditional active agent, more preferably at least two additional activeagents, still more preferably at least three or four additional activeagents, which can be formulated in accordance with their respectiveconventional dosing protocols, e.g., IR, XR or DR. In preferredembodiments, the fixed-dose pharmaceutical compositions further compriseat least one anti-hypertensive, and optionally at least oneanti-platelet agent.

In exemplary embodiments, the pharmaceutical composition comprises amulti-layer tablet, or a capsule with three or or more componentsencapsulated in appropriately-formulated mini-tablets. Also providedherein are methods of treating hyperglycemic conditions in patients inneed thereof, comprising administering the subject compositions to saidpatients either once- or twice daily. In preferred embodiments, thebiguanide compound is selected from the group consisting of metformin,buformin, phenformin and imeglimin, and is administered at lower dosesand/or with lower bioavailability than currently indicated while stillachieving the desired metabolic improvements.

Definitions

The terms “gastrointestinal tract” and “gut,” as used herein, refer tothe stomach and intestine. The “small” or “upper” intestine includes theduodenum, jejunum and ileum and the “large” or “lower” intestineincludes the caecum, colon and rectum. The “distal” small intestineincludes the jejunum and ileum.

“Treating” or “treatment” of any condition, disease or disorder refers,in some embodiments, to ameliorating the disease, disorder, or condition(i.e., arresting or reducing the development of the disease, disorder,or condition, or at least one of the clinical symptoms thereof). Inother embodiments “treating” or “treatment” refers to ameliorating atleast one physical parameter, which may or may not be discernible by thesubject, including physical parameters that are undesired but notclinically significant. In yet other embodiments, “treating” or“treatment” refers to inhibiting the disease, disorder, or condition,either physically, (e.g., stabilization of a discernible symptom),physiologically, (e.g., stabilization of a physical parameter) or both.“Preventing” or “prevention” of any condition, disease or disorderrefers to preventing or delaying the onset of disease development ifnone had occurred, preventing or delaying the disease or disorder fromoccurring in a subject that may be predisposed to the disorder ordisease but has not yet been diagnosed as having the disorder ordisease, and/or preventing or delaying further disease development ifalready present.

“Therapeutically effective amount” or “effective amount” means theamount of a composition, compound, therapy, or course of treatment that,when administered to a subject for treating a disease, disorder, orcondition, is sufficient to effect such treatment for the disease,disorder, or condition. The “therapeutically effective amount” will varydepending on the composition, the compound, the therapy, the course oftreatment, the disease, disorder, or condition, and its severity and theage, weight, etc., of the subject to be treated.

When the biguanide compounds described herein include one or more chiralcenters, the stereochemistry of such chiral centers can independently bein the R or S configuration, or a mixture of the two. The chiral centerscan be further designated as R or S or R,S or d,D, 1,L or d,l, D,L.Correspondingly, the biguanide compounds of the invention, if they canbe present in optically active form, can actually be present in the formof a racemic mixture of enantiomers, or in the form of either of theseparate enantiomers in substantially isolated and purified form, or asa mixture comprising any relative proportions of the enantiomers.

When the biguanide compounds described herein contain two or more chiralcenters then diastereomers are possible. Such diastereomers may bepresent as pure diastereomeric enantiomers, pure racemic mixtures ofdiastereomeric enantiomers, mixtures of diastereomers which may beracemic or may have optical activity in their own right due to complexpermutations of enantiomeric diastereomers in the balance of themixtures.

When the biguanide compounds of the invention, if they can be present ingeometrically isomeric forms around, for example, the guanide bond, thenthey can actually be present in the form of a mixture of geometricisomers comprising any relative proportions of the isomers, or in somecases in the form of either of the separate geometric isomers insubstantially isolated and purified form.

When the biguanide compounds described herein include one or moreisolated or linearly conjugated double bonds, the geometry around suchdouble bonds can be independently a cis/trans, E/Z mixture or an E or Zgeometric isomer thereof.

“Alkyl” means a straight or branched chain, saturated monovalenthydrocarbon radical. By way of example, the hydrocarbon chain may havefrom one to twenty carbons, one to sixteen carbons, one to fourteencarbons, one to twelve carbons, one to ten carbons, one to eightcarbons, one to six carbons, one to four carbons, etc. “Lower alkyl” mayrefer to alkyls having, e.g., one to six carbons, one to four carbons,etc. In certain examples, an straight chain alkyl may have from one tosix carbon atoms and a branched alkyl three to six carbon atoms, e.g.,methyl, ethyl, propyl, 2-propyl, butyl (including all isomeric forms),pentyl (including all isomeric forms), and the like. “Me” means methyl,“Et” means ethyl, and “iPr” means isopropyl.

“Aryl” means a monovalent monocyclic or bicyclic aromatic hydrocarbonradical, e.g., having from of 6 to 20 or 6 to 10 ring atoms e.g., phenylor naphthyl.

“Alkylaryl” means a (alkylene)-R radical where R is aryl as definedabove.

“Cycloalkyl” means a cyclic saturated or partially saturated monovalenthydrocarbon radical (or an alicyclic radical). By way of example, thecycloalkyl may have from three to twenty carbon atoms, from three tosixteen carbon atoms, from three to fourteen carbon atoms, from three totwelve carbon atoms, from three to ten carbon atoms, from three to eightcarbon atoms, from three to six carbon atoms, etc., wherein one or twocarbon atoms may be replaced by an oxo group, e.g., admantanyl,cyclopropyl, cyclobutyl, cyclopentyl, cyclohexyl, cyclohexenyl, indanyland the like.

“Alkylcycloalkyl” means a (alkylene)-R radical where R is cycloalkyl asdefined above; e.g., cyclopropylmethyl, cyclobutylmethyl,cyclopentylethyl, or cyclohexylmethyl, and the like.

“Heterocyclyl” or “heterocycloalkyl” means a saturated or unsaturatedmonovalent monocyclic group, in which one or two ring atoms areheteroatom selected from N, O, or S, the remaining ring atoms being C.The heterocyclyl ring is optionally fused to a (one) aryl or heteroarylring as defined herein. The heterocyclyl ring fused to monocyclic arylor heteroaryl ring is also referred to in this Application as “bicyclicheterocyclyl” ring. Additionally, one or two ring carbon atoms in theheterocyclyl ring can optionally be replaced by a —CO— group. Morespecifically the term heterocyclyl includes, but is not limited to,pyrrolidino, piperidino, homopiperidino, 2-oxopyrrolidinyl,2-oxopiperidinyl, morpholino, piperazino, tetrahydropyranyl,thiomorpholino, and the like. When the heterocyclyl ring is unsaturatedit can contain one or two ring double bonds. When the heterocyclyl groupcontains at least one nitrogen atom, it is also referred to herein asheterocycloamino and is a subset of the heterocyclyl group. When theheterocyclyl group is a saturated ring and is not fused to aryl orheteroaryl ring as stated above, it is also referred to herein assaturated monocyclic heterocyclyl.

“Alkylheterocycloalkyl” means a -(alkylene)-R radical where R isheterocyclyl ring as defined above e.g., tetraydrofuranylmethyl,piperazinylmethyl, morpholinylethyl, and the like.

“Heteroaryl” means a monovalent monocyclic or bicyclic aromatic radical,where one or more, preferably one, two, or three, ring atoms areheteroatom selected from N, O, or S, the remaining ring atoms beingcarbon. Representative examples include, but are not limited to,pyrrolyl, thienyl, thiazolyl, imidazolyl, furanyl, indolyl, isoindolyl,oxazolyl, isoxazolyl, diazolyl, pyrazolyl, triazolyl, benzothiazolyl,benzoxazolyl, quinolinyl, isoquinolinyl, pyridinyl, pyrimidinyl,pyrazinyl, pyridazinyl, tetrazolyl, and the like.

“Oxo” or “carbonyl” means ═(O) group or CO═O group, respectively.

The term “substituted” means that the referenced group is substitutedwith one or more additional group(s) individually and independentlyselected from groups described herein. In some embodiments, an optionalsubstituent is selected from oxo, halogen, —CN, —NH₂, —OH, —NH(CH₃),—N(CH₃)₂, alkyl (including straight chain, branched and/or unsaturatedalkyl), substituted or unsubstituted cycloalkyl, substituted orunsubstituted heterocycloalkyl, fluoroalkyl, substituted orunsubstituted heteroalkyl, substituted or unsubstituted alkoxy,fluoroalkoxy, —S-alkyl, —S(O)₂-alkyl, —CONH((substituted orunsubstituted alkyl) or (substituted or unsubstituted phenyl)), —CON(Hor alkyl)₂, —OCON(substituted or unsubstituted alkyl)₂,—NHCONH((substituted or unsubstituted alkyl) or (substituted orunsubstituted phenyl)), —NHCOalkyl, —N(substituted or unsubstitutedalkyl)CO(substituted or unsubstituted alkyl), —NHCOO(substituted orunsubstituted alkyl), —C(OH)(substituted or unsubstituted alkyl)₂, and—C(NH₂)(substituted or unsubstituted alkyl)₂. In some embodiments, byway of example, an optional substituent is selected from oxo, fluorine,chlorine, bromine, iodine, —CN, —NH₂, —OH, —NH(CH₃), —N(CH₃)₂, —CH₃,—CH₂CH₃, —CH(CH₃)₂, —CF₃, —CH₂CF₃, —OCH₃, —OCH₂CH₃, —OCH(CH₃)₂, —OCF₃,—OCH₂CF₃, —S(O)₂—CH₃, —CONH₂, —CONHCH₃, —NHCONHCH₃, —COCH₃, —COOH andthe like. In some embodiments, substituted groups are substituted withone, two or three of the preceding groups. In some embodiments,substituted groups are substituted with one or two of the precedinggroups. In some embodiments, substituted groups are substituted with oneof the preceding groups. Further, unless stated to the contrary, aformula with chemical bonds shown only as solid lines and not as wedgesor dashed lines contemplates each possible isomer, e.g., each enantiomerand diastereomer, and a mixture of isomers, such as racemic or scalemicmixtures.

In some embodiments, a biguanide compound of the disclosure is presentin a composition as a salt. In some embodiments, salts are obtained byreacting a compound of the disclosure with acids. In some otherembodiments, pharmaceutically acceptable salts are obtained by reactinga compound of the disclosure with a base. In other embodiments, thecompounds are used as free-acid or free-base form in the manufacture ofthe compositions described herein. The type of salts, include, but arenot limited to: (1) acid addition salts, formed by reacting the freebase form of the compound with a pharmaceutically acceptable: inorganicacid, such as, for example, hydrochloric acid, hydrobromic acid,sulfuric acid, phosphoric acid, metaphosphoric acid, and the like; orwith an organic acid, such as, for example, acetic acid, propionic acid,hexanoic acid, cyclopentanepropionic acid, glycolic acid, pyruvic acid,lactic acid, malonic acid, succinic acid, malic acid, maleic acid,fumaric acid, trifluoroacetic acid, tartaric acid, citric acid, benzoicacid, 3-(4-hydroxybenzoyl)benzoic acid, cinnamic acid, mandelic acid,methanesulfonic acid, ethanesulfonic acid, 1,2-ethanedisulfonic acid,2-hydroxyethanesulfonic acid, benzenesulfonic acid, toluenesulfonicacid, 2-naphthalenesulfonic acid,4-methylbicyclo-[2.2.2]oct-2-ene-1-carboxylic acid, glucoheptonic acid,4,4′-methylenebis-(3-hydroxy-2-ene-1-carboxylic acid), 3-phenylpropionicacid, trimethylacetic acid, tertiary butylacetic acid, lauryl sulfuricacid, gluconic acid, glutamic acid, hydroxynaphthoic acid, salicylicacid, stearic acid, muconic acid, butyric acid, phenylacetic acid,phenylbutyric acid, valproic acid, and the like; (2) salts formed whenan acidic proton present in the parent compound is replaced by a metalion, e.g., an alkali metal ion (e.g. lithium, sodium, potassium), analkaline earth ion (e.g. magnesium, or calcium), or an aluminum ion. Insome cases, the biguanide compound described herein are reacted with anorganic base, such as, but not limited to, ethanolamine, diethanolamine,triethanolamine, tromethamine, N-methylglucamine, dicyclohexylamine,tris(hydroxymethyl)methylamine. In other cases, the compounds describedherein form salts with amino acids such as, but not limited to,arginine, lysine, and the like. Acceptable inorganic bases used to formsalts with compounds that include an acidic proton, include, but are notlimited to, aluminum hydroxide, calcium hydroxide, potassium hydroxide,sodium carbonate, sodium hydroxide, and the like.

The term “amino acid” includes any one of the twenty naturally-occurringamino acids or the D-form of any one of the naturally-occurring aminoacids. In addition, the term “amino acid” also includes othernon-naturally occurring amino acids besides the D-amino acids, which arefunctional equivalents of the naturally-occurring amino acids. Suchnon-naturally-occurring amino acids include, for example, norleucine(“Nle”), norvaline (“Nva”), L- or D-naphthalanine, ornithine (“Om”),homoarginine (homoArg) and others well known in the peptide art, such asthose described in M. Bodanzsky, “Principles of Peptide Synthesis,” 1stand 2nd Revised Ed., Springer-Verlag, New York, N.Y., 1984 and 1993, andStewart and Young, “Solid Phase Peptide Synthesis,” 2nd Ed., PierceChemical Co., Rockford, Ill., 1984, both of which are incorporatedherein by reference.

Amino acids and amino acid analogs can be purchased commercially (SigmaChemical Co.; Advanced Chemtech) or synthesized using methods known inthe art.

In the scope of the embodiments, the biguanide compounds describedherein include further forms of the compounds such as pharmaceuticallyacceptable salts, solvates (including hydrates), amorphous phases,partially crystalline and crystalline forms (including all polymorphs),prodrugs, metabolites, N-oxides, isotopically-labeled, epimers, pureepimers, epimer mixtures, enantiomers including but not limited tosingle enantiomers and enantiomeric diastereomers, meso compounds,stereoisomers, racemic mixtures and diasteroisomeric mixtures. Biguanidecompounds described herein having one or more double bonds includecis/trans isomers, E/Z isomers and geometric isomers. Biguanidecompounds described herein can be prepared as a pharmaceuticallyacceptable salts formed when an acidic proton present in the parentcompound either is replaced by a metal ion, for example an alkali metalion, an alkaline earth ion, or an aluminum ion; or coordinates with anorganic base. In addition, the salt forms of the disclosed compounds canbe prepared using salts of the starting materials or intermediates.

In some embodiments, the biguanide compounds described herein includesolvent addition forms or crystal forms thereof; particularly solvatesor polymorphs. Solvates contain either stoichiometric ornon-stoichiometric amounts of a solvent, and may be formed during theprocess of crystallization with pharmaceutically acceptable solventssuch as water, ethanol, and the like. Hydrates are formed when thesolvent is water, or alcoholates are formed when the solvent is alcohol.

As noted above, in some embodiments the biguanide compounds describedherein possess one or more stereocenters and each center existsindependently in either the R or S configuration. The biguanidecompounds presented herein include all diastereomeric, enantiomeric, andepimeric forms as well as the appropriate mixtures thereof.

In some embodiments, sites on the biguanide compounds disclosed hereinare susceptible to various metabolic reactions. Therefore incorporationof appropriate substituents at the places of metabolic reactions willreduce, minimize or eliminate the metabolic pathways. In specificembodiments, the appropriate substituent to decrease or eliminate thesusceptibility of the aromatic ring to metabolic reactions is, by way ofexample only, a halogen, deuterium or an alkyl group.

In some embodiments, the biguanide compounds described herein areisotopically-labeled, which are identical to those recited in thevarious formulae and structures presented herein, but for the fact thatone or more atoms are replaced by an atom having an atomic mass or massnumber different from the atomic mass or mass number usually found innature. In some embodiments, one or more hydrogen atoms are replacedwith deuterium. In some embodiments, metabolic sites on the compoundsdescribed herein arc deutcrated. In some embodiments, substitution withdeuterium affords certain therapeutic advantages resulting from greatermetabolic stability, such as, for example, increased in vivo half-lifeor reduced dosage requirements. Throughout the specification, groups andsubstituents thereof can be chosen by one skilled in the field toprovide stable moieties and compounds.

Statins

Suitable HMG-CoA reductase inhibitors or statins for use in the subjectinvention include, e.g. lovastatin, atorvastatin, fluvastatin,rosuvastatin, simvastatin, pravastatin, pitavastatin, mevastatin, andthe like. Alternative agents capable of decreasing triglyceride and/orLDL levels include but are not limited to ascorbic acid, asparaginase,clofibrate, colestipol, cholestyrine, fenofibrate, gemfibrozil,nicotinic acid, mevinolin, probucol and omega-3 fatty acid. These agentsare generally formulated for immediate-release, although extended-and/or delayed-release may also be utilized.

Biguanides

The compositions and methods disclosed herein relate to metformin andother biguanides. By way of background, metformin is one of the simpleststructural variants of a class of compounds known as the biguanides.From a structural perspective metformin resembles a pharmacophore orfragment of a larger biologically active chemical structure.

In one embodiment, the biguanide compounds of the subject inventioninclude the following:

wherein:

R₁, R₂, R₃, R₄, R₅, R₆, and R₇ are independently selected from:

H, OH,

O-Rx, wherein Rx is alkyl, cycloalkyl, alkylcycloalkyl, acyl, ester,thioester;

optionally substituted alkyl (e.g., a C₁ to C₁₂ straight chain orbranched chain alkyl optionally substituted with oxygen, silicon,sulphur or optionally substituted with OH, O-alkyl, SH, S-alkyl, NH₂,NH-alkyl); cycloalkyl (e.g., C₃ to C₇ cycloalkyl); alkylcycloalkyl(e.g., C₄ to C₁₂ alkylcycloalkyl); heterocycloalkyl (e.g., where theheterocycle comprises one or two hetero atoms selected from O, S, or N,including a C₂ to C₆ heterocycloalkyl); alkylheterocycloalkyl (e.g.,where the heterocycle comprises one or two hetero atoms selected from O,S, or N, including a C₃ to C₁₁ alkylheterocycloalkyl, and includingwherein when N is present in the heterocyclic ring, the nitrogen atommay be in the form of an amide, carbamate or urea); optionallysubstituted alkenyl (e.g., C₁ to C₁₂ straight chain or branched chainalkenyl optionally substituted with oxygen, silicon, sulphur oroptionally substituted with OH, O-alkyl, SH, S-alkyl, NH₂, NH-alkyl);optionally substituted alkynyl (e.g., C₁ to C₁₂ straight chain orbranched chain alkynyl optionally substituted with oxygen, silicon,sulphur or optionally substituted with OH, O-alkyl, SH, S-alkyl, NH₂,NH-alkyl);

optionally substituted aryl (e.g., phenyl, substituted phenyl, naphthyl,substituted naphthyl); optionally substituted alkylaryl (e.g.,alkylphenyl, alkylsubstituted phenyl, alkylnaphthyl, alkylsubstitutednaphthyl); optionally substituted heteroaryl (e.g., pyridyl, furanyl,thiophenyl, pyrrollyl, oxazolyl, isoxazolyl, thiazolyl, diazolyl,pyrazolyl, triazolyl all of which are optionally substituted);optionally substituted alkylheteroaryl; and

or R₆ and R₇ may join to form a bond, together forming a ring includingthe nitrogen atoms to which they are attached;

or R₁ and R₂ may together form a 3 to 8 membered heterocyclic ring,including the nitrogen atoms to which they are attached;

or R₄ and R₅ may together form a ring selected from the group aziridine,pyrrolyl, imidazolyl, pyrazolyl, indolyl, indolinyl, pyrrolidinyl,piperazinyl and piperidyl, including the nitrogen atoms to which theyare attached.

In certain embodiments, O-Rx may be selected from: O—C₁ to C₈ straightchain or branched chain alkyl; O—C₃ to C₇ cycloalkyl; O—C₄ to C₈alkylcycloalkyl; O-acyl; O-esters; and O-thioesters.

In other embodiments, optional substitutions may include, e.g., OH,O-alkyl, SH, S-alkyl, NH₂, NH-alkyl. Further, an alkyl, alkenyl,alkynyl, etc. may be substituted with an oxygen, silicon, sulphur, etc.to form a heteroalkyl, heteroalkenyl, heteroalkynyl, etc.

In certain embodiments, each of: R₃, R₆, and R₇, or R₃, R₄, R₅, and R₇,or R₃, R₄, R₅, and R₇, or R₃, R₄, R₅, R₆ and R₇, or R₂, R₃, R₄, R₅, R₆and R₇ are independently selected from:

H, methyl, ethyl, propyl or isopropyl;

and each of the remaining substituent groups: R₁, R₂, R₄, and R₅, or R₁,R₂, and R₆, or R₁, R₂, and R₆, or R₁ and R₂, or R₁, respectively, areindependently selected from:

H; optionally substituted alkyl (e.g., C₁ to C₁₂ straight chain orbranched chain alkyl optionally hetero substituted with oxygen, silicon,sulphur or optionally substituted with OH, O-alkyl, SH, S-alkyl, NH₂,NH-alkyl); optionally substituted alkenyl (e.g., C₁ to C₁₂ straightchain or branched chain alkenyl optionally hetero substituted withoxygen, silicon, sulphur or optionally substituted with OH, O-alkyl, SH,S-alkyl, NH₂, NH-alkyl); optionally substituted alkynyl (e.g., C₁ to C₁₂straight chain or branched chain alkynyl optionally hetero substitutedwith oxygen, silicon, sulphur or optionally substituted with OH,O-alkyl, SH, S-alkyl, NH₂, NH-alkyl); cycloalkyl (e.g., C₃ to C₇cycloalkyl); alkylcycloalkyl (e.g., C₄ to C₁₂ alkylcycloalkyl);heterocycloalkyl (e.g., where the heterocycle comprises one or twohetero atoms selected from O, S, or N, including C₂ to C₆heterocycloalkyl); alkylheterocycloalkyl (e.g., where the heterocyclecomprises one or two hetero atoms selected from O, S, or N, including C₃to C₁₁ alkylheterocycloalkyl, and including wherein when N is present inthe heterocyclic ring, the nitrogen atom may be in the form of an amide,carbamate or urea); aryl (e.g., phenyl, substituted phenyl, naphthyl,substituted naphthyl); alkylaryl (e.g., alkylphenyl, alkylsubstitutedphenyl, alkylnaphthyl, alkylsubstituted naphthyl); heteroaryl (e.g.,pyridyl, furanyl, thiophenyl, pyrrollyl, oxazolyl, isoxazolyl,thiazolyl, diazolyl, pyrazolyl, triazolyl all of which are optionallysubstituted); alkylheteroaryl;

or R₁ and R₂ may together form a 3 to 8 membered heterocyclic ring,including the nitrogen atoms to which they are attached;

or R₄ and R₅ may together form a ring selected from the group aziridine,pyrrolyl, imidazolyl, pyrazolyl, indolyl, indolinyl, pyrrolidinyl,piperazinyl and piperidyl, including the nitrogen atoms to which theyare attached.

Exemplary compounds and substituents of R₁, R₂, R₃, R₄, R₅, R₆, and R₇of Formula I are shown below. Additional combinations of selections ofsubstituents of R₁, R₂, R₃, R₄, R₅, R₆, and R₇ are envisioned anddisclosed in co-pending U.S. patent application Ser. No. 13/547,022, thedisclosure of which is expressly incorporated by reference herein.

In certain embodiments, the biguanide compounds of Formula I may includean asymmetric center or centers, and may be in the form of a compositionof a racemic mixture, a diastereoisomeric mixture, a single enantiomer,an enantiomeric diastereomer, a meso compound, a pure epimer, or amixture of epimers thereof, etc. Further, the biguanide compounds mayhave one or more double bonds, and may be in a form of a cis/trans, E/Zmixture or an E or Z geometric isomer thereof.

The biguanide compounds of Formula I may also be prepared as a saltform, e.g., pharmaceutically acceptable salts, including suitable acidforms, e.g., salt forms selected from hydrochloride, hydrobromide,acetate, propionate, butyrate, sulphate, hydrogen sulphate, sulphite,carbonate, hydrogen carbonate, phosphate, phosphinate, oxalate,hemi-oxalate, malonate, hemi-malonate, fumarate, hemi-fumarate, maleate,hemi-maleate, citrate, hemi-citrate, tartrate, hemi-tartrate, aspartate,glutamate, etc.

Alternative embodiments of biguanide compounds specifically contemplatedfor use in the subject invention include the related heterocycliccompounds described in co-pending U.S. patent application Ser. No.13/547,022, the disclosure of which is expressly incorporated herein byreference. The phrase “biguanide compound” as used herein includes theserelated heterocyclic compounds, exemplary embodiments of which includethe following:

In one embodiment, the compounds of the disclosure may be prepared as athree component salt form including the components A, B, and C wherein:

-   -   A is the protonated form of a natural or unnatural amino acid;    -   B is the dianion of an acid; and    -   C is the protonated form of a Compound of Formula I.

In certain aspects, stoichiometric amounts of A, B, and C may beincluded wherein:

-   -   A is the protonated form of a natural amino acid selected from        alanine, asp artic acid, asparagine, arginine, glycine,        glutamine, glutamic acid lysine, phenylalanine, tyrosine,        scrinc, thrconinc, tryptophan, lcucinc, isolcucinc, histidinc,        mcthioninc, prolinc, cystcinc, or cystine;    -   B is the dianion of an acid selected from oxalic, malonic,        citric, maleic, fumaric, tartaric, aspartic, glutamic acids and        the like; and    -   C is the protonated form of a compound of Formula I.

Expanded Uses of Biguanide Compounds, including Metformin

Since systemic biguanides, including metformin are reported to besubstantially excreted by the kidney, the risk of biguanide compoundaccumulation and lactic acidosis increases with the degree of impairmentof renal function. Related contraindications for biguanide compoundssuch as metformin include impaired lactate clearance, and hypoxicconditions caused by, e.g., respiratory or heart failure. Accordingly,patients having these contraindications are not currently treatable withconventional formulations. Moreover, the current diabetic patientpopulation being treated with conventional metformin formulations oftensuffer from a range of intractable and ultimately dose-limitinggastrointestinal side effects including nausea, vomiting and diarrhea,and accordingly the more widespread use of these compounds in a broaderpatient population has thus far been avoided.

However, as demonstrated herein, the therapeutic efficacy of metforminand other biguanide compounds does not actually require the systemicexposure of metformin that presents an increased risk of lacticacidosis. Moreover, the occurrence of GI side effects can also besignificantly reduced by employing delayed-release formulations, andaccordingly the methods and compositions provided herein can be safelyand effectively used for a wider range of cardiometabolic conditions ina much broader population of patients in need thereof, includingreducing cardiometabolic risk in general, and treating or preventingcardiovascular disease in particular.

Cardiovascular Disease

The term “cardiovascular disease” herein refers to any disease ordisorder of the heart or blood vessels (i.e. arteries and veins) or anysymptom thereof, or any disease or condition that causes or contributesto a cardiovascular disease.” Non-limiting examples of cardiovasculardiseases include acute cardiac ischemic events, acute myocardialinfarction, angina, angina pectoris, arrhythmia, atrial fibrulation,atherosclerosis, arterial fibrillation, cardiac insufficiency,cardiovascular disease, chronic heart failure, chronic stable angina,congestive heart failure, coronary artery disease, coronary heartdisease, deep vein thrombosis, diabetes, diabetes mellitus, diabeticneuropathy, diastolic dysfunction in subjects with diabetes mellitus,edema, essential hypertension, eventual pulmonary embolism, fatty liverdisease, heart disease, heart failure, homozygous familialhypercholesterolemia (HoFH), homozygous familial sitosterolemia,hypercholesterolemia, hyperlipidemia, hyperlipidemia in HIV positivesubjects, hypertension, hypertriglyceridemia, ischemic complications inunstable angina and myocardial infarction, low blood pressure, metabolicsyndrome, mixed dyslipidemia, moderate to mild heart failure, myocardialinfarction, obesity management, paroxysmal atrial/arterialfibrillation/fibrulation/flutter, paroxysmal supraventriculartachycardias (PSVT), particularly severe or rapid onset edema, plateletaggregation, primary hypercholesterolemia, primary hyperlipidemia,pulmonary arterial hypertension, pulmonary hypertension, recurrenthemodynamically unstable ventricular tachycardia (VT), recurrentventricular arrhythmias, recurrent ventricular fibrillation (VF),ruptured aneurysm, sitisterolemia, stroke, supraventricular tachycardia,symptomatic atrial fibrillation/flutter, tachycardia, type-II diabetes,vascular disease, venous thromboembolism, ventricular arrhythmias, andother cardiovascular events.

Metabolic Disorders

The compositions and methods of the present invention also findadvantageous use in the treatment and/or prophylaxis of metabolicdisorders, including being overweight, obesity, prediabetes, PolycysticOvary Syndrome, dislipidemia or disorders of lipid metabolism, as wellas hyperglycemic conditions, such as insulin-dependent (type 1) or-independent (type 2) diabetes, as well as physiological conditions ordisorders associated with or that result from the hyperglycemiccondition. Thus, hyperglycemic conditions treatable by a method of theinvention also include a histopathological change associated withchronic or acute hyperglycemia (e.g., diabetes). Particular examplesinclude degeneration of pancreas (13-cell destruction), kidney tubulecalcification, degeneration of liver, eye damage (diabetic retinopathy),diabetic foot, ulcerations in mucosa such as mouth and gums, excessbleeding, delayed blood coagulation or wound healing and increased riskof coronary heart disease, stroke, peripheral vascular disease,dyslipidemia, hypertension and obesity.

As used herein, the term “hyperglycemic” or “hyperglycemia,” when usedin reference to a condition of a patient, means a transient or chronicabnormally high level of glucose present in the blood of a patient. Thecondition can be caused by a delay in glucose metabolism or absorptionsuch that the patient exhibits glucose intolerance or a state ofelevated glucose not typically found in normal patients (e.g., inglucose-intolerant subdiabetic patients at risk of developing diabetes,or in diabetic patients). Fasting plasma glucose (FPG) levels fornormoglycemia are less than about 110 mg/dl, for impaired glucosemetabolism, between about 110 and 126 mg/dl, and for diabetics greaterthan about 126 mg/dl.

Metabolic disorders also include obesity or an undesirable body mass.Leptin, cholecystokinin, PYY and GLP-1 decrease hunger, increase energyexpenditure, induce weight loss or provide normal glucose homeostasis.Thus, in various embodiments, a method of the invention for treatingobesity or an undesirable body mass, or hyperglycemia, involves thelocal administration of metformin to activate enteroendocrine cellproduction of cholecystokinin, oxyntomodulin, GIP, GLP-2, PYY or GLP-1.Disorders treatable also include those typically associated withobesity, for example, abnormally elevated serum/plasma LDL, VLDL,triglycerides, cholesterol, plaque formation leading to narrowing orblockage of blood vessels, increased risk of hypertension/stroke,coronary heart disease, etc.

Synthesis of the Compounds

Compounds described herein may be synthesized using standard synthetictechniques known to those of skill in the art or using methods known inthe art in combination with methods described herein. In additions,solvents, temperatures and other reaction conditions presented hereinmay vary according to the practice and knowledge of those of skill inthe art.

The starting material used for the synthesis of compounds describedherein can be obtained from commercial sources, such as Aldrich ChemicalCo. (Milwaukee, Wis.), Sigma Chemical Co. (St. Louis, Mo.), or thestarting materials can be synthesized. The compounds described herein,and other related compounds having different substituents can besynthesized using techniques and materials known to those of skill inthe art, such as described, for example, in March, ADVANCED ORGANICCHEMISTRY 4th Ed., (Wiley 1992); Carey and Sundberg, ADVANCED ORGANICCHEMISTRY 4th Ed., Vols. A and B (Plenum 2000, 2001), and Green andWuts, PROTECTIVE GROUPS IN ORGANIC SYNTHESIS 3rd Ed., (Wiley 1999) (allof which are incorporated by reference in their entirety). Generalmethods for the preparation of the compounds as disclosed herein may bederived from known reactions in the field, and the reactions may bemodified by the use of appropriate reagents and conditions, as would berecognized by the skilled person, for the introduction of the variousmoieties found in the formulae as provided herein.

Additional biguanide synthesis methods and schemes for the compoundsdescribed herein can be found in U.S. application Ser. No. 12/593,479(published as U.S. 2010/0130498); U.S. application Ser. No. 12/593,398(published as U.S. 2010/0184796); U.S. Pat. No. 7,829,299; U.S.application Ser. No. 11/578,013 (published as U.S. 2010/0056621); U.S.Pat. No. 7,416,867; U.S. application Ser. No. 11/455,693 (published asU.S. 2007/0037212); U.S. application Ser. No. 13/059,730 (published asU.S. 2011/0143376), U.S. Application Ser. No. 12/996,670 (published asU.S. 2011/0311991), U.S. Pat. No. 7,811,788; U.S. application Ser. No.11/182,942 (published as U.S. 2006/0019346); U.S. application Ser. No.12/993,542 (published as U.S. 2011/0086138), U.S. application Ser. No.12/373,235 (published as U.S. 2010/0055209); International ApplicationSer. No. PCT/IL2007/000454 (published as WO 2007/116404); U.S.application Ser. No. 10/472,056 (published as U.S. 2004/0138189); U.S.Pat. No. 5,891,919; U.S. Pat. No. 6,376,657; U.S. application Ser. No.11/554,982 (published as U.S. 2007/0104805); U.S. application Ser. No.11/926,745 (published as U.S. 2008/0108604); International ApplicationSer. No. PCT/CA2009/001688 (published as WO 2010/060198); U.S.application Ser. No. 12/735,557 (published as U.S. 2010/0330205);International Application Ser. No. PCT/CA2007/001066 (published as WO2008/000063); U.S. application Ser. No. 11/438,204 (published as U.S.2006/0269617); U.S. application Ser. No. 10/563,713 (published as U.S.2006/0172020); U.S. application Ser. No. 10/902,352 (published as U.S.2006/0024335); U.S. application Ser. No. 10/538,038 (published as U.S.2006/0275765), U.S. application Ser. No. 11/555,617 (published as U.S.2008/0187936); U.S. application Ser. No. 12/739,264 (published as U.S.2010/0316736); U.S. application Ser. No. 12/215,609 (published as U.S.2009/0042813); U.S. application Ser. No. 11/893,088 (published as U.S.2008/0050499); U.S. Pat. No. 7,807,204; U.S. application Ser. No.11/811,166 (published as U.S. 2008/0003268); U.S. Pat. No. 6,376,657;International Application Ser. No. PCT/US2011/041183 (published as WO2011/163183); International Application Ser. No. PCT/EP2011/059814(published as WO 2011/157692); U.S. application Ser. No. 12/790,292(published as U.S. 2011/0293753); International Application Ser. No.PCT/JP2009/071700 (published as WO 2010/076879); U.S. application Ser.No. 13/032,530 (published as U.S. 2011/0217394); InternationalApplication Ser. No. PCT/EP2011/000110 (published as WO 2011/085979);International Application Ser. No. PCT/US2010/058467 (published as WO2011/068814); U.S. application Ser. No. 13/060,996 (published as U.S.2011/0152361); U.S. application Ser. No. 12/09,253 (published as U.S.2011/0124609); U.S. application Ser. No. 12/687,962 (published as U.S.2011/0119499); and International Application Ser. No. PCT/EP2010/004623(published as WO 2011/012298); each of which are incorporated byreference in their entirety.

Administration and Methods

The biguanide compounds of the disclosure, including analogs, salts,solvates, polymorphs, hydrates, N-oxides, and prodrugs of suchcompounds, may be administered to a subject in need thereof to reducecardiometabolic risk in general, and to treat and/or preventcardiovascular disease in particular. In view of the decoupling ofsystemic bioavailability and therapeutic efficacy achieved herein, andthe surprising reduction in related GI toxicities, the effective use ofsuch compounds in the broader patient population exhibiting one or morecardiometabolic risk factors, and/or suffering from or at risk ofcardiovascular disease, can now be successfully and safely achieved.

In preferred embodiments, the compound is metformin. Prior formulationsof metformin are reported to have an average bioavailability of 30% to60% while many comparable small molecules have bioavailability ofgreater than 60%. See, e.g., Tucker et al., “Metformin kinetics inhealthy subjects and in patients with diabetes mellitus” Br. J. Clin.Pharmacol. 1981, 12(2) 235-246. Notably, metformin administrationincreases plasma concentrations of GLP-1 in normal, diabetic andDPP-IV-deficient rodents, as well as in humans with and without type IIdiabetes, but has been reported to do so indirectly and independent of adirect impact on intestinal L cells. Mulherin et al., supra.

As demonstrated herein, however, and contrary to the well-establishedconvention in the art, enteroendocrine activation by metformin may betriggered by luminal signals on the epithelial aspect of the gut, andtherefore systemic bioavailability of metformin is actually unnecessaryafter oral ingestion in order to stimulate the release ofgastrointestinal hormones such as GLP-1. Accordingly, the effectivetreatment of otherwise contraindicated patients is now made possible byadministering compositions comprising biguanide compounds (includinganalogs, salts, solvates, polymorphs, hydrates, N-oxides, and prodrugsthereof) adapted to minimize the systemic bioavailability of thecompound. In preferred embodiments, the subject compositions and methodsare formulated so as to minimize and preferably avoid an initial releasein the stomach and/or proximal small intestine (areas with the greatestabsorption) in order to reduce systemic bioavailability upon oraladministration.

Delivery to Specific Intestinal Locations

The embodiments described herein provide a treatment method comprisingadministering a delayed-release composition comprising a biguanidecompound (including any analogs, salts, solvates, polymorphs, hydrates,N-oxides, or prodrugs thereof) formulated to be delivered to one or morelocations of the small intestine and/or lower intestine, and preferablydistal small intestine, in order to minimize systemic bioavailability byavoiding absorption in the stomach and proximal small intestine andcorresponding rapid increase in C_(max).

The biguanide compounds are targeted beyond the stomach to one or moreregions of the small intestine, and are preferably targeted downstreamor distal of the duodenum. In preferred embodiments, the compounds aredelivered to the jejunum, ileum, caecum and colon, or a combinationthereof. In preferred embodiments, the compounds are delivered to thejejunum, ileum and caecum, or a combination thereof. In preferredembodiments, the compounds are preferentially targeted to the ileum. Inadditional embodiments, the compound is delivered downstream or distalof the jejunum, or solely to the lower intestine.

In yet other embodiments, the biguanide compound (including an analog,salt, solvate, polymorph, hydrate, N-oxide, or prodrug thereof) isdelivered to one or more regions of the upper intestine and one or moreregions of the lower intestine. For example, the compound can bedelivered to the duodenum and the colon. In another non-limitingexample, the compound can be delivered to the duodenum, jejunum, ileumand colon.

The administration of biguanides such as metformin to the preferredregions or locations of the intestine may be achieved by any knownmethod. In preferred embodiments, the biguanide compound is formulatedin a delayed-release composition for oral delivery that delivers thecompound to the targeted regions or locations of the intestine. Whendelivery of the biguanide compound is targeted to two or more regions ofthe gastrointestinal tract, the compound may be delivered in anyproportion and manner.

Minimizing Systemic Exposure

As described above, the methods disclosed herein minimize the systemicbioavailability of the biguanide compound. In some embodiments, thebiguanide compounds have reduced average systemic bioavailability.Reduced average systemic bioavailabity, in some embodiments, is loweraverage systemic bioavailability as compared to an immediate-release orextended-release formulation having an equivalent amount of thebiguanide compound. In other embodiments, reduced average systemicbioavailability is when the average systemic bioavailability is morethan a 50% reduction, more than a 40% or 45% reduction, more than a 30%or 35% reduction, more than a 20% or 25% reduction , and more than a 10%or 15% reduction in average systemic bioavailability in comparison withan immediate- or extended-release formulation having an equivalentamount of the biguanide compound.

In some embodiments, the subject methods minimize the mean plasmaC_(max) and/or mean AUC levels of the biguanide compound incontraindicated patients. In some embodiments, the administrationmethods result in minimal plasma absorption, mean C_(max) and/or meanAUC levels of the biguanide compounds in the patient. It otherembodiments, the mean plasma C_(max), and/or mean AUC levels of thebiguanide compound are considered sub-therapeutic for the describedcompositions as compared to the reported C_(max) and/or AUC levels ofconventional immediate-release and extended-release formulations havingidentical amounts of metformin. For example, negligible orsub-therapeutic metformin plasma C_(max) and/or AUC levels include 75%,60%, 50%, 40% and 30% of reported C_(max) and/or AUC levels of knownmetformin formulations (e.g., GLUMETZA®, GLUCOPHAGE®, GLUCOPHAGE® XR,RIOMET®, FORTAMET®, OBIMET®, GLUFORMIN®, DIANBEN®, DIABEX®, DIAFORMIN®,Metformin Metformin SR®, and the like).

In specific embodiments, the inventive compositions and methods directedto metformin produce a C_(max) that is no more than 75% or 85%,preferably no more than 50% or 60%, more preferably no more than 25% or30% or 40% of the same dose of an immediate release metforminformulation (e.g. GLUCOPHAGE®) following oral ingestion. In otherembodiments, the inventive methods provide a C_(max) that is no morethan 3×, more preferably no more than 2.5× or 2×, still more preferablyno more than 1.8× or 1.5× the initial trough plasma concentration 10-12hours after the last oral ingestion of metformin. In other embodiments,the inventive compositions and methods provide a mean plasma AUC overthe dosing interval that is no more than 75% or 80%, preferably no morethan 50% or 60%, more preferably no more than 25%, 30% or 40% of thesame dose of an immediate release formulation (e.g. GLUCOPHAGE®)following oral ingestion.

Accordingly, in specific embodiments, administration of the subjectdelayed-release formulation minimizes the mean plasma AUC, the meanplasma C_(max) and/or the circulating plasma concentration of thebiguanide compound in contraindicated patients compared to an identicalprotocol administering an IR or XR formulation having the same amount ofthe biguanide compound. In one embodiment, the mean plasma AUC_(0-∞) ofthe biguanide compound resulting from administration is less than about15,000 ng*h/mL or 14,000 ng*h/mL, preferably less than about 12,000ng*h/mL, 11,000 ng*h/mL or 10,000 ng*h/mL, more preferably less thanabout 9,000 ng*h/mL, 8,000 ng*h/mL or 7,000 ng*h/mL. In one embodiment,the resulting mean plasma C_(max) of the biguanide compound is less thanabout 1000 ng/mL, preferably less than about 900 ng/mL or 800 ng/mL,more preferably less than about 700 ng/mL, 600 ng/mL or 500 ng/mL. Inone embodiment, the resulting circulating plasma concentration of thebiguanide compound is below about 5 μg/ml or 4 μg/ml, preferably belowabout 3 μg/ml or 2.5 μg/ml, more preferably below about 2 μg/ml, 1μg/ml, 0.5 μg/ml, or 0.25 μg/ml in the patient. In preferredembodiments, the biguanide compound is metformin, the IR composition isGlucophage® and the XR composition is Glucophage® XR.

Additional Active Agents

As noted above the present invention contemplates fixed-dose oral dosageforms combining a delayed-release formulation of metformin or otherbiguanide compounds with appropriate conventional formulations of atleast one statin and at least one additional active agent, morepreferably at least two additional active agents, still more preferablyat least three or four additional active agents, including, e.g.anti-hypertensives, anti-platelet agents, diuretics, bile acidsequesterants, incretin mimetics, oral anti-diabetic agents,anti-obesity agents, and anti-atheroscicrotics. These combination dosageforms provide for additive and/or synergistic effects, resulting in theneed for lower dosages of a known therapy, the compositions describedherein, or both. Additional benefits of combination therapies includethe reduction in toxicities associated with any of the known therapies.

Suitable anti-hypertensives for use in the subject invention include,e.g., beta blockers (atenolol, betaxolol, metoprolol, nadolol,nebivolol, oxprenolol, pindolol, propranolol, timolol, etc.), alpha-1blockers (alfuzosin, arotinolol, doxazosin, indoramin, moxisylyte,phenoxybenzamine, phentolamine, prazosin, silodosin, tamsulosin,terazosin, tolazoline, trimazosin), alpha-2 agonists (apraclonidinc,brimonidinc, clonidine, guanabenz, guanfacine, lofexidine, tolonidine,mixed alpha/beta blockers (bucindolol, carvedilol, labetalol, etc.),calcium channel blockers such as dihydropyridines (amlodipine,felodipine, isradipine, lercanidipine, nicardipine, nifedipine,nimodipine, nitrendipine, etc.) and non-dihydropyridines (diltiazem,verapamil, etc.), renin inhibitors (aliskiren), ACE inhibitors(captopril, enalapril, fosinopril, lisinopril, perindopril, quinapril,ramipril, trandolapril, benazepril, etc.), angiotensin II receptorantagonists (candesartan, eprosartan, irbesartan, losartan, olmesartan,telmisartan, valsartan, etc.), and the like. These agents are generallyformulated for immediate-release, although extended- and/ordelayed-release may also be utilized.

Suitable anti-platelet medications for use in the subject inventioninclude, e.g., cyclooxygenase inhibitors (acetylsalicylic acid(aspirin), aloxiprin, carbasalate calcium, indobufen, trifusal, etc.),ADP receptor inhibitors (clopidogrel, ticlopidine, ticagrelor, etc.),phosphodiesterase inhibitors (cilostazol, etc.), adenose reuptakeinhibitors (dipyridamole, etc.), thromboxane synthase or receptorinhibitors (picotamide, ramatroban, terbogrel, etc.), anagrelide,prasugrcl, cloricromen, and the like. These agents arc generallyformulated for immediate-release, although extended- and/ordelayed-release may also be utilized.

Suitable diuretics for use in the subject invention include e.g., loopdiuretics (bumetanide, ethacrynic acid, furosemide, torsemide, etc.),thiazide diuretics (epitizide, hydrochlorothiazide, chlorothiazide,bendroflumethiazide, etc.), thiazide-like diuretics (indapamide,chlorthalidone, metolazone, etc.), potassium-sparing diuretics(amiloride, triamterene, spironolactone, etc.), and the like. Theseagents are generally formulated for immediate-release, althoughextended- and/or delayed-release may also be utilized.

Suitable bile acid sequesterants for use in the subject inventioninclude, e.g., cholestyramine, colesevelam, colestipol, and the like.These agents are generally formulated for immediate-release, althoughextended- and/or delayed-release may also be utilized.

Suitable incretin mimetics and enhancers for use in the subjectinvention include, e.g., peptidic and non-peptidic GLP-1 mimetics(including, e.g., allosteric activators of the GLP-1 receptor), peptidicand non-peptidic PYY mimetics, peptidic and non-peptidic Ghrelinantagonists and the like. These agents are generally formulated forimmediate-release, although extended- and/or delayed-release may also beutilized.

Suitable oral anti-diabetic agents for use in combination with metforminin the subject compositions and methods include, e.g., sulfonylureas(glyburide, glimepiride, glipizide, gliclazide, glycopyramide,gliquidone, tolbutamide, acetohexamide, tolazamide, chlorpropamide,carbutamide, etc.), nonsulfonylureas (repaglinide, nateglinide, etc.),thiazolidinediones (rosiglitazone, pioglitazone, rivoglitazone,troglitazone, ciglitazone, darglitazone, netoglitazone, englitazone,etc.), dual PPAR agonists (e.g., aleglitazar, farglitazar, muraglitazar,tesaglitazar, telmisartan, and the like), dipeptidyl peptidase-4inhibitors (vildagliptin, sitagliptin, saxagliptin, linagliptin,allogliptin, septagliptin, berberine, etc.), sodium-glucoseco-transporter-1 or 2 (SGLT1 or SGLT2) inhibitors (canagliflozin,empagliflozin, dapagliflozin, LX4211, etc.) meglitinides (nateglinide,repaglinide, etc.), alpha-glucosidase inhibitors (acarbose, miglitol,voglibose, etc.), GPR119 agonists (anandamide, AR-231, 453, MBX-2982;Oleoylethanolamide, PSN-365,963, PSN-632,408, palmitoylethanolamide,etc.), GPR120 agonists (omega-3 fatty acids including, but not limitedto, a-linolenic acid, docosapentaenoic acid, docosahexaenoic acid,eicosatrienoic acid, eicosatetraenoic acid, eicosapentaenoic acid,heneicosapentaenoic acid, hexadecatrienoic acid, stearidonic acid,tetracosahexaenoic acid, tetracosapentaenoic acid, etc.), and GPR 40,GPR41 and GPR 43 agonists (e.g., free fatty acids including short-,medium-, and long-chain saturated and unsaturated fatty acids). Theseagents are generally formulated for immediate-release, althoughextended- and/or delayed-release may also be utilized.

Suitable GPR40, GPR41 and GPR43 agonists are also described in thefollowing publications and patent applications: Stoddart L A, Smith N J,Milligan G. International Union of Pharmacology. LXXI. Free fatty acidreceptors FFA1, -2, and-3: pharmacology and pathophysiological functionsPharmacol Rev. (2008) December; 60(4):405-417; Trond Ulven. Short-chainfree fatty acid receptors FFA2/GPR43 and FFA3/GPR41 as new potentialtherapeutic targets Front Endocrinol (Lausanne) (2012); 3: 111;WO/2012/147516—Cyclic amide derivative; WO/2012/147518—Novel3-hydroxyisothiazole 1-oxide derivative; WO/2012/136221—Ortho-fluorosubstituted compounds for the treatment of metabolic diseases;WO/2012/072691—Indanyloxydihydrobenzofuranylacetic acids;WO/2012/046869—Cyclic amide derivative; WO/2012/010413—Aryloxy-alkylenesubstituted hydroxyphenyl hexynoic acids, methods for the productionthereof and use of the same as medicament; WO/2012/011125—Agonists ofGPR40; WO/2012/004269—(2-aryloxy-acetylamino)-phenyl-propionic acidderivatives, method for producing same and use thereof aspharmaceuticals; WO/2011/161030—Heterocyclic substituted methoxyphenylderivatives having an oxo group, method for producing same, and usethereof as GPR40 receptor modulators; WO/2011/078371—Novel3-hydroxy-5-arylisothiazole derivative; WO/2011/069958—Low caloric fatreplacers; WO/2011/052756—Novel 3-hydroxy-5-arylisoxazole derivative;WO/2011/044073—Pyrrolidine GPR40 modulators; WO/2010/143733—Novel fusedcyclic compound and use thereof; WO/2010/123016—Carboxylic acidcompound; WO/2010/123017—tetrazole compound;WO/2010/091176—Phthalazine-containing antidiabetic compounds;WO/2010/085522—Pentafluorosulpholane-containing antidiabetic compounds;WO/2010/085528—Bridged and fused antidiabetic compounds;WO/2010/085525—Bridged and fused heterocyclic antidiabetic compounds;WO/2010/045258—Spirocyclic GPR40 modulators; WO/2010/012650—Compoundsfor the treatment of metabolic diseases; WO/2009/058237—Antidiabetictricyclic compounds; WO/2009/054423—Oxadiazolidinedione compound;WO/2009/054423—Oxadiazolidinedione compound;WO/2009/054390—Thiazolidinedione compound; WO/2009/048527—Substitutedbiphenyl GPR40 modulators; WO/2009/038204—Novel long-chain fatty acidderivative compound and G-protein-coupled receptor agonist containingthe compound as active ingredient; WO/2008/139987—G-protein-conjugatedreceptor agonist; WO/2008/130514—Substituted biphenyl phenoxy-;thiophenyl- and aminophenylpropanoic acid GPR40 modulators;WO/2008/066097—Carboxylic acid derivative; WO/2008/054675—Antidiabeticbicyclic compounds; WO/2008/054674—Antidiabetic bicyclic compounds;WO/2008/030520—heterocyclic GPR40 modulators; WO/2008/001931—fusedcyclic compounds; WO/2007/136572—antidiabetic bicyclic compounds;WO/2007/136573—antidiabetic bicyclic compounds;WO/2007/123225—Oxadiazolidinedione compound; WO/2007/049050—Modulatorsof GPR40 for the treatment of diabetes;WO/2007/013689—Cyclopropanecarboxylic acid compound;WO/2007/013689—Cyclopropanecarboxylic acid compound;WO/2006/083781—Antidiabetic bicyclic compounds;WO/2006/083612—Antidiabetic bicyclic compounds; WO/2006/038738—Receptorfunction regulating agent; WO/2006/011615—Remedy for diabetes;WO/2005/095338—Alkoxyphenylpropanoic acid derivatives;WO/2005/087710—Aminophenylpropanoic acid derivative;WO/2005/063729—3-(4-benzyloxyphenyl)propanoic acid derivatives;WO/2005/063725—Phenylpropanoic acid derivatives;WO/2005/051890—Aminophenylcyclopropyl carboxylic acids and derivativesas agonists to GPR40; WO/2004/106276—Condensed ring compound;WO/2004/072650—Diagnostics and therapeutics for diseases associated withG protein-coupled receptor 40 (GPR40); WO/2004/041266—Receptor functioncontrolling agent; WO/2006/102653—Methods and compositions for treatinginsulin resistance and obesity-induced diseases; WO/2006/052566—GPR41and modulators thereof for the treatment of insulin-related disorders;WO/2004/038421—Diagnostics and therapeutics for diseases associated withhuman G protein-coupled receptor 41 (GPR41);WO/2001/061359—Identification of modulators of GPR41 or GPR42 activity;WO/2011/151436—Azepin-derivatives as derivatives as G-protein coupledreceptor (GPR43) agonists; WO/2011/092284—Novel amino acid derivativesand their use as GPR43 receptor modulators; WO/2011/073376—Pyrrolidineor thiazolidine carboxylic acid derivatives, pharmaceutical compositionand methods for use in treating metabolic disorders as agonists ofG-protein coupled receptor 43 (GPR43); WO/2006/102653—Methods andcompositions for treating insulin resistance and obesity-induceddiseases; WO/2006/036688—GPR43 and modulators thereof for the treatmentof metabolic-related disorders; WO/2004/038405—Diagnostics andtherapeutics for diseases associated with G protein-coupled receptor 43(GPR43); WO/2003/057730—Ligand for g-protein coupled receptor GPR43 anduses thereof; WO/2000/028083—Mouse 7-transmembrane receptor GPR43; eachof which are incorporated by reference in their entirety. These agentsare generally formulated for immediate-release, although extended-and/or delayed-release may also be utilized.

Suitable GPR119 agonists are described in the following patentapplications: WO/2013/055910—Modulators of the GPR119 receptor and thetreatment of disorders related thereto; WO/2013/011402—GPR 119modulators; WO/2012/173174—Azaspiroalkane compound;WO/2012/173174—Azaspiroalkane compound; WO/2012/168315—Substitutedpiperidines as GPR119 modulators for the treatment of metabolicdisorders; WO/2012/170702—Modulators of the GPR119 receptor and thetreatment of disorders related thereto; WO/2012/154009—Thienopyrimidinederivatives; pharmaceutically acceptable salts thereof; method forpreparing thienopyrimidine derivatives; and pharmaceutical compositioncontaining thienopyrimidine derivatives as active ingredients forpreventing or treating diabetes-related diseases;WO/2012/145603—Modulators of the GPR119 receptor and the treatment ofdisorders related thereto; WO/2012/145361—Modulators of the GPR119receptor and the treatment of disorders related thereto;WO/2012/145604—Modulators of the GPR119 receptor and the treatment ofdisorders related thereto; WO/2012/135570—Modulators of the GPR119receptor and the treatment of disorders related thereto;WO/2012/123449—N-cyclopropyl-N-piperidinylbenzamides as GPR119modulators; WO/2012/111995—Oxime derivatives as GPR119 agonists;WO/2012/103806—Bicyclic heteroaryl compounds as GPR119 receptoragonists; WO/2012/098217—Fused dihydrofurans as GPR119 modulators forthe treatment of diabetes, obesity and related disorders;WO/2012/093809—New bicyclic compound for modulating G protein-coupledreceptors; WO/2012/080476—Fused dihydropyrans as GPR119 modulators forthe treatment of diabetes, obesity and related diseases;WO/2012/077655—Spiro derivative having GPR119 agonist activity;WO/2012/069948—4-(5-cyano-pyrazol-1-yl)-piperidine derivatives as GPR119modulators; WO/2012/069917—Bicyclic GPR119 modulators;WO/2012/046792—GPR119 agonist; WO/2012/046249—Novel GPR119 agonists;WO/2012/041158—Tricyclic compound, preparation method and pharmaceuticaluse thereof; WO/2012/040279—Modulators of the GPR119 receptor and thetreatment of disorders related thereto;WO/2012/037393—Piperidinyl-substituted lactams as GPR119 modulators;WO/2012/025811—Indolylpyrimidines as modulators of GPR119;WO/2012/011707—Substituted pyridinone derivatives and methods formanufacturing the same; WO/2012/006955—Compounds for treatment ofmetabolic disorders; WO/2011/159657—Bicyclic heterocycle derivatives andmethods of use thereof; WO/2011/148922—Novel quinazoline compound;WO/2011/147951—Cycloamino derivatives as GPR119 agonists;WO/2011/146335—Piperidinyl-substituted lactams as GPR119 modulators;WO/2011/145718—Novel pyrrolo[2,3-d]pyrimidine compound;WO/2011/140160—Bicyclic heteroaryl compounds as GPR119 modulators;WO/2011/138427—Pyridazinones as GPR119 agonists;WO/2011/140161—Benzofuranyl analogues as GPR119 modulators;WO/2011/128394—3-substituted 5-(pyrrolidinc-1-carbonyl) pyrrolidinc andits derivatives for use in the treatment of metabolic disorders;WO/2011/128395—N-substituted 3-amino 4-(pyrrolidine-1-carbonyl)pyrrolidine and its derivatives for use in the treatment of metabolicdisorders; WO/2011/127051—Modulators of the GPR119 receptor and thetreatment of disorders related thereto;WO/2011/127106—Pyrimidinylpiperidinyloxypyridinone analogues as GPR119modulators; WO/2011/113947—Combination of a GPR119 agonist and thedpp-iv inhibitor linagliptin for use in the treatment of diabetes andrelated conditions; WO/2011/093501—GPR119 agonist; WO/2011/078306—GPR119agonist; WO/2011/066137—Substituted biaryl derivatives and methods ofuse thereof; WO/2011/061679—Imidazo-pyrazoles as GPR119 inhibitors;WO/2011/055770—Fused heterocyclic compound; WO/2011/053688—Bridgedbicyclic piperidine derivatives and methods of use thereof;WO/2011/044001—Compounds and compositions as modulators of GPR119activity; WO/2011/036576—GPR119 modulators;WO/2011/030139—4-(pyrimidin-2-yl)-piperazine and4-(pyrimidin-2-yl)-piperidine derivatives as GPR119 modulators;WO/2011/025006—GPR119 agonist; WO/2011/014520—Compounds and compositionsas modulators of GPR119 activity; WO/2011/008663—GPR119 agonists;WO/2011/005929—Piperidine derivative and its use for the treatment ofdiabetes and obesity; WO/2010/140092—1-(piperidin-4-yl)-pyrazolederivatives as GPR119 modulators; WO/2010/128414—GPR119 modulators;WO/2010/128425—GPR119 modulators; WO/2010/123018—Diazaspiroalkanederivative; WO/2010/106457—3-oxa-7-azabicyclo[3.3.1]nonanes;WO/2010/103334—Compounds for the treatment of metabolic disorders;WO/2010/103333—Compounds for the treatment of metabolic disorders;WO/2010/103335—Compounds for the treatment of metabolic disorders;WO/2010/095663—Fused heterocyclic ring compound;WO/2010/088518—Heterocyclic modulators of GPR119 for treatment ofdisease; WO/2010/084944—Novel pyrrolo[2,3-d]pyrimidine compound;WO/2010/074271—Therapeutic agent for diabetes;WO/2010/048149—Heterocyclic modulators of GPR119 for treatment ofdisease; WO/2010/029089—Combination therapy for the treatment ofdiabetes and related conditions; WO/2010/013849—GPR119 agonist;WO/2010/008739—Aryl GPR119 agonists and uses thereof;WO/2010/009195—Bicyclic heterocycle derivatives and use thereof asGPR119 modulators; WO/2010/009183—Pyridone and pyridazone analogues asGPR119 modulators; WO/2010/006191—4-phenoxymethylpiperidines asmodulators of GPR119 activity; WO/2010/004348—Heterocyclic GPCRagonists; WO/2010/004347—Heterocyclic GPCR agonists;WO/2010/001166—Thiazolc derivatives as GPR119 modulators;WO/2009/150144—New GPR119modulators; WO/2009/141238—GPR119 receptoragonists; WO/2009/143049—Bicyclic heterocycle derivatives and usethereof as GPR119 modulators; WO/2009/126245—Methods of using a Gprotein-coupled receptor to identify peptide YY (PYY) secretagogues andcompounds useful in the treatment of conditions modulated by PYY;WO/2009/126535—Compounds and compositions as modulators of GPR119activity; WO/2009/123992—Oxymethylene aryl compounds and uses thereof;WO/2009/117421—Heterocyclic modulators of GPR119 for treatment ofdisease; WO/2009/106561—Pyrazine compounds for treating GPR119 relateddisorders; WO/2009/106565—Agonists of GPR119; WO/2009/105715—Compoundsand compositions as modulators of GPR119 activity;WO/2009/105722—Compounds and compositions as modulators of GPR119activity; WO/2009/105717—Compounds and compositions as modulators ofGPR119 activity; WO/2009/055331—Bicyclic heterocycle derivatives andtheir use as modulators of the activity of GPR119;WO/2009/050522—Azetidinyl G-protein coupled receptor agonists;WO/2009/050523—Azetidinyl G-protcin coupled receptor agonists;WO/2009/038974—Compounds and compositions as modulators of GPR119activity; WO/2009/034388—Compounds for the treatment of metabolicdisorders; WO/2009/014910—N-azacyclic substituted pyrrole, pyrazole,imidazole, triazole and tetrazole derivatives as agonists of the RUP3 orGPR119 receptor for the treatment of diabetes and metabolic disorders;WO/2009/012277—Method for modulating GPR119 G protein-coupled receptorand selected compounds; WO/2009/012275—Pyridone GPR119 G protein-coupledreceptor agonists; WO/2008/137436—[6,5]-bicyclic GPR119 Gprotein-coupled receptor agonists; WO/2008/137435—[6,6] and[6,7]-bicyclic GPR119 G protein-coupled receptor agonists;WO/2008/130584—Pyrimidinone derivatives and methods of use thereof;WO/2008/130581—Pyrimidinone derivatives and methods of use thereof;WO/2008/130615—Tetrahydropyrido[4,3-d]pyrimidinone derivatives andmethods of use thereof; WO/2008/109702—Compounds and compositions asmodulators of GPR119 activity; WO/2008/097428—Compounds and compositionsas modulators of GPR119 activity; WO/2008/025799—Pyridazine compoundsfor treating GPR119 related disorders; WO/2008/025798—Pyridine compoundsfor treating GPR119 related disorders; WO/2008/025800—Pyrimidinecompounds for treating GPR119 related disorders; WO/2008/008887—GPR119agonists for treating metabolic disorders; WO/2008/008895—GPR119agonists for the treatment of diabetes and related disorders;WO/2007/120702—Use of GPR119 receptor agonists for increasing bone massand for treating osteoporosis; and combination therapy relating thereto;WO/2007/120689—Methods of using GPR119 receptor to identify compoundsuseful for increasing bone mass in an individual;WO/2007/116229—Heterocyclic GPCR agonists; WO/2007/116230—Azetidinederivatives as G-protein coupled receptor (GPR119) agonists;WO/2006/076231—Combination therapy for the treatment of diabetes andconditions related thereto and for the treatment of conditionsameliorated by increasing a blood GLP-1 level; each of which areincorporated by reference in their entirety. These agents are generallyformulated for immediate-release, although extended- and/ordelayed-release may also be utilized.

Suitable GPR120 agonists are described in the following patentapplications: WO/2012/058649—Cis3,4-dihydroxy-2-(3-methylbutanoyl)-5-(-3-methylbutyl)-4-(4-methylpentanoyl)cyclopent-2-en-1-onederivatives, substantially enantiomerically pure compositions andmethods; WO/2011/159297—GPR120 receptor agonists and uses thereof;WO/2011/072132—Methods of treating inflammatory conditions;WO/2010/080537—GPR120 receptor agonists and uses thereof;WO/2010/048207—Aryl GPR120 receptor agonists and uses thereof;WO/2009/147990—Novel isoxazole derivative; WO/2009/125804—Screeningmethod; WO/2009/038204—Novel long-chain fatty acid derivative compoundand G-protein-coupled receptor agonist containing the compound as activeingredient; WO/2008/139987—G-protein-conjugated receptor agonist;WO/2008/103500—Thiazole derivatives as modulators of G protein-coupledreceptors; WO/2008/066131—Novel phenyl-isoxazol-3-ol derivative;WO/2007/134613—Modulation of GPR120 activity in adipocytes/fat tissue;WO/2007/026874—Method for screening of substance effective on diseaseusing GPR120 and phospholipase; WO/2007/014824—Fat taste receptors andtheir methods of use; each of which are incorporated by reference intheir entirety. These agents are generally formulated forimmediate-release, although extended- and/or delayed-release may also beutilized.

Suitable anti-obesity agents for use for use in subject inventioninclude, e.g., Orlistat (Zenical), Lorcaserin (Belviq), Sibutramine(Meridia), Rimonabant (Acomplia), Exenatide (Byetta and Bydureon),Pramlintide (Symlin), Fen-Phen, Redux, ZGN-433, Phentermine/topiramate(Qsymia), Naltrexone/buproprion (Contrave), as well as alternativemedicine options including, e.g., conjugated linoleic acid, green teaextract, khat, lipoic acid, ECA Stack (Ephedrine Caffeine Stack),Raspberry ketone and the like. These agents are generally formulated forimmediate-release, although extended-release or delayed-release may alsobe utilized.

Suitable anti-artherosclerotics for use in the subject invention includecompounds that can reduce atherosclerosis independent of changes inother risk factors, e.g. fish oil as well as inhibitors of proproteinconvertase subtilisin/kexin type 9 (PCSK9) such as AMG145 (Amgen),1D05-IgG2 (Merck & Co.), and SAR236553/REGN727 (Aventis/Regeneron),peptides mimicking the LDLR that binds to PCSK9 (e.g. Shan et al. (2008)Biochem. Biophys. Res. Commun. 375: 69-73), and nucleic acidtherapeutics targeting PCSK9 (e.g Graham et al. (2007) J. Lipid Res.48:763-7; Lindholm et al. (2012) Mol. Ther. 20:376-81).

Also contemplated as additional active agents are HDL/LDL ratiomodifying compounds including, e.g., niacin, acipomox, MK-0354, othermodulators of GPR81, GPR109A, GPR109B and the like. Suitable modulatorsof GPR81, GPR109A and GPR109B are described in the following paper andpatent applications: Offermanns S, Colletti S L, Lovenberg T W, SempleG, Wise A, I Jzerman A P. International Union of Basic and ClinicalPharmacology. LXXXII: Nomenclature and Classification ofHydroxy-carboxylic Acid Receptors (GPR81, GPR109A, and GPR109B)Pharnzacol Rev. (2011) June; 63(2):269-90. doi: 10.1124/pr.110.003301.Epub 2011 Mar. 31; WO/2010/030360—3H-imidazo[4,5-b]pyridin-5-olderivatives useful in the treatment of GPR81 receptor disorders;WO/2008/063321—GPR81-ligand complexes and their preparation and use;WO/2011/057110—GPR109A agonists for the treatment of cerebral ischemia;WO/2011/044136—Fatty acid acipimox derivatives and their uses;WO/2011/044139—Fatty acid acifran derivatives and their uses;WO/2011/028689—Fatty acid niacin conjugates and their uses;WO/2009/033078—Compositions and methods for controlling cholesterollevels; WO/2008/144423—Compositions comprising a GPR109 ligand fortreating disorders of the digestive tract and/or cancer;WO/2007/021744—Methods for determining probability of an adverse orfavorable reaction to a niacin receptor agonist;WO/2009/151542—Nicotinic acid receptor ligands;WO/2006/127595—5-aminopyrazole carboxylic acid derivatives and methodsof treatment of metabolic-related disorders thereof;WO/2006/069242—Fused pyrazole derivatives and uses thereof in methods oftreatment of metabolic-related disorders;WO/2005/051937—4-oxo-4;5-dihydro-furan-2-carboxylic and acid derivativesand methods of treatment of metabolic-related disorders thereof;WO/2005/044816—Tetrazole derivatives and methods of treatment ofmetabolic-related disorders thereof; WO/2005/028488—Heteroarylphosphinyl and thiophosphinyl compounds for regulation of glucose,triglycerides, and LDL/HDL levels; WO/2005/011677—5-substituted2h-pyrazole-3-carboxylic acid derivatives as agonists for the nicotinicacid receptor RUP25 for the treatment of dyslipidemia and relateddiseases; WO/2004/033431—Hydroxypyrazoles for use againstmetabolic-related disorders; WO/2004/032928—5-substituted2H-pyrazone-3-carboxylic acid derivatives as antilipolytic agents forthe treatment of metabolic-related disorders such as dyslipidemia; eachof which are incorporated by reference in their entirety. These agentsare generally formulated for immediate-release, although extended-and/or delayed-release may also be utilized.

In alternative embodiments, the subject compositions and methods areadministered in conjunction with anti-psychotics or anti-depressantswhich have a propensity to induce weight gain, and/or pre-diabetes anddiabetes. Suitable anti-psychotics for use for use in conjunction withthe subject compositions and methods include, e.g., Haloperidol (Haldol,Serenace) Droperidol (Droleptan, Inapsine), Chlorpromazine (Thorazine,Largactil), Fluphenazine (Prolixin), Perphenazine (Trilafon),Prochlorperazine (Compazine), Thioridazine (Mellaril), Trifluoperazine(Stelazine), Mesoridazine (Serentil), Periciazine, Promazine.Triflupromazine (Vesprin), Levomepromazine (Nozinan), Promethazine(Phenergan), Pimozide (Orap), Cyamemazine (Tercian), Chlorprothixene(Cloxan, Taractan, Truxal), Clopenthixol (Sordinol), Flupenthixol(Depixol, Fluanxol), Thiothixene (Navane), Zuclopenthixol (Cisordinol,Clopixol, Acuphase), Clozapine (Clozaril), Olanzapine (Zyprexa),Risperidone (Risperdal), Quetiapine (Seroquel), Ziprasidone (Geodon),Amisulpride (Solian), Asenapine (Saphris), Paliperidone (Invega),Iloperidone (Fanapt, Fanapta, and previously known as Zomaril), Zotepine(Nipolept, Losizopilon, Lodopin, Setous), Sertindole (Serdolect, andSerlect in Mexico), Lurasidone (Latuda), Aripiprazole, (Abilify),partial agonists of dopamine receptors, Cannabidiol, Tetrabenazine,metabotropic glutamate receptor 2 agonists (e.g. LY2140023), glycinetransporter 1 inhibitors (e.g. RG1678), L-threonine, and the like. Theseagents are generally formulated for immediate-release, althoughextended- and/or delayed-release may also be utilized.

Suitable anti-depressants which have a propensity to induce weight gain,and/or pre-diabetes and diabetes for use for use in conjunction with thesubject compositions and methods include, e.g., Citalopram (Celexa),Escitalopram (Lexapro, Cipralex), Paroxetine (Paxil, Seroxat),Fluoxetine (Prozac), Fluvoxamine (Luvox), Sertraline (Zoloft, Lustral),Atomoxetine (Strattera), Reboxetine (Edronax), Viloxazine (Vivalan),Mianserin (Tolvon), Mirtazapine (Remeron, Avanza, Zispin),Desvenlafaxine (Pristiq), Duloxetine (Cymbalta), Milnacipran (Ixel,Savella), Venlafaxine (Effexor), Etoperidone (Axiomin, Etonin),Nefazodone (Serzone, Nefadar), Trazodone (Desyrel),Norepinephrine-dopamine reuptake inhibitors, Bupropion (Wellbutrin,Zyban), Tianeptine (Stablon, Coaxil, Tatinol), Amineptine, Agomelatine(Valdoxan, Melitor, Thymanax), Amitriptyline (Elavil, Endep),Clomipramine (Anafranil), Doxepin (Adapin, Sincquan), Imipramine(Tofranil), Trimipramine (Surmontil), Dcsipraminc (Norpramin),Nortriptyline (Pamelor, Aventyl, Noritren), Protriptyline (Vivactil),Isocarboxazid (Marplan), Moclobemide (Aurorix, Manerix), Phenelzine(Nardil), Pirlindole (Pirazidol), Selegiline (Eldepryl, Emsam),Tranylcypromine (Parnate) and the like. These agents are generallyformulated for immediate-release, although extended- and/ordelayed-release may also be utilized.

In certain embodiments, compositions provided herein may be used withother commercially available diet aids or other weight loss and/oranti-obesity agents, such as, by way of example, PYY and PYY agonists,GLP-1 and GLP-1 agonists, CCK and CCK agonists, exendin and exendinagonists, GIP and GIP agonists, amylin and amylin agonists, ghrelinmodulators (e.g., inhibitors) and leptin and leptin agonists. In certaininstances, compositions comprising the biguanide compound providedherein are used in combination with amylin, amylin agonists or mimetics.Exemplary amylin agonists or mimetics include pramlintide and relatedcompounds. In certain instances, the compounds and compositions providedherein are used in combination with leptin, leptin agonists or mimetics.Additional leptin agonists or mimetics can be identified using themethods described by U.S. Pat. No. 7,247,427 which is incorporated byreference herein. In further instances, the compounds and compositionsprovided herein increase leptin sensitivity and increase effectivenessof leptin, leptin agonists or mimetics.

Additional anti-obesity agents suitable for use in the subject methodsinclude those that are in current development. Other anti-obesity agentsinclude phentermine, fenfluramine, sibutramine, rimonabant, topiramate,zonisamide, bupropion, naltrexone, lorcaserin, or relatedsympathomimetics and orlistat or other intestinal lipase inhibitors,alone or in combination. Therapies, drugs and compounds useful for thetreatment of weight loss, binge eating, food addictions and cravings maybe administered with the compositions described herein. For example, thepatient may further be administered at least one other drug which isknown to suppress hunger or control appetite. Such therapies drugs andcompounds include but are not limited to phenteramines such as Meridia®and Xenical®. Additional therapies, drugs and compounds are known in theart and contemplated herein.

As such, in another aspect, the subject compositions and methods may beused as part of a combination therapy for the control, prevention ortreatment of obesity or eating disorders or conditions. Compounds usedas part of a combination therapy to treat obesity or reduce weightinclude, but are not limited to, central nervous system agents thataffect neurotransmitters or neural ion channels, includingantidepressants (bupropion), noradrenalin reuptake inhibitors(GW320659), selective 5HT 2c receptor agonists, antiseizure agents(topiramate, zonisamide), some dopamine antagonists, and cannabinoid-1receptor antagonists (CB-1 receptor antagonists) (rimonabant);leptin/insulin/central nervous system pathway agents, including leptinanalogues, leptin transport and/or leptin receptor promoters, ciliaryneurotrophic factor (Axokine), neuropeptide Y and agouti-related peptideantagonists, pro-opiomelanocortin and cocaine and amphetamine regulatedtranscript promoters, .alpha.-melanocyte-stimulating hormone analogues,melanocoritin-4 receptor agonists, and agents that affect insulinmetabolism/activity, which include protein-tyrosine phosphatase-1Binhibitors, peroxisome proliferator activated receptor-gamma receptorantagonists, short-acting bromocriptine (ergoset), somatostatin agonists(octreotide), and adiponectin/Acrp30 (Famoxin or Fatty Acid MetabolicOxidation Inducer); gastrointestinal-neural pathway agents, includingthose that increase cholecystokinin activity (CCK), PYY activity, NPYactivity, and PP activity, increase glucagon-like peptide-1 activity(exendin 4, liraglutide, dipeptidyl peptidase IV inhibitors), and thosethat decrease ghrelin activity, as well as amylin analogues(pramlintide); agents that may increase resting metabolic rate(selective (3-3 stimulators/agonist, uncoupling protein homologues, andthyroid receptor agonists); other more diverse agents, including melaninconcentrating hormone antagonists, phytostanol analogues, functionaloils, P57, amylase inhibitors, growth hormone fragments, syntheticanalogues of dehydroepiandrosterone sulfate, antagonists of adipocyte11B-hydroxysteroid dehydrogenase type 1 activity,corticotropin-releasing hormone agonists, inhibitors of fatty acidsynthesis (cerulenin and C75), carboxypeptidase inhibitors,indanone/indanols, amino sterols (trodusquemine/trodulamine), and othergastrointestinal lipase inhibitors (ATL962); amphetamines, such asdextroamphetamine; other sympathomimetic adrenergic agents, includingphentermine, benzphetamine, phendimetrazine, mazindol, anddiethylpropion.

Other active agents of interest include ecopipam; oxyntomodulin (OM);inhibitors of glucose-dependent insulinotropic polypeptide (GIP);gastrin-releasing peptide; neuromedin B; enterostatin; amfebutamone,SR-58611; CP-045598; AOD-0604; QC-BT16; rGLP-1; 1426 (HMR-1426); N

5984; ISIS-113715; solabegron; SR-147778; Org-34517; melanotan-II;cetilistat; c-2735; c-5093; c

2624; APD-356; radafaxine; fluasterone; GP-389255; 856464; S-2367;AVE-1625; T-71; olcoyl-estrone; peptide YY [3-36] intranasal; androgenreceptor agonists; PYY 3-36; DOV-102677; tagatose; SLV-319; 1954(Aventis Pharma AG); oxyntomodulin, Thiakis; bromocriptine, PLTVA;diabetes/hyperlipidemia therapy, Yissum; CKD-502; thyroid receptor betaagonists; beta-3 adrenoceptor agonist; CDK-A agonists; galaninantagonist; dopamine Dl/D2 agonists; melanocortin modulators;verongamine; neuropeptide Y antagonists; melanin-concentrating hormonereceptor antagonists; dual PPAR alpha/gamma agonists; CGEN-P-4; kinaseinhibitors; human MCH receptor antagonists; GHS-R antagonists; ghrelinreceptor agonists; DG70 inhibitors; cotinine; CRF-BP inhibitors;urocortin agonists; UCL-2000; impentamine; .beta.-3 adrenergic receptor;pentapeptide MC4 agonists; trodusquemine; GT-2016; C-75; CPOP; MCH-1receptor antagonists; RED-103004; aminosterols; orexin-1 antagonists;neuropeptide Y5 receptor antagonists; DRF-4158; PT-15; PTPaseinhibitors; A37215; SA-0204; glycolipid metabolites; MC-4 agonist;produlestan; PTP-1B inhibitors; GT-2394; neuropeptide Y5 antagonists;melanocortin receptor modulators; MLN-4760; PPAR gamma/delta dualagonists; NPY5RA-972; 5-HT2C receptor agonist; neuropeptide Y5 receptorantagonists (phenyl urea analogs); AGRP/MC4 antagonists; neuropeptide Y5antagonists (benzimidazole); glucocorticoid antagonists; MCHR1antagonists; Acetyl-CoA carboxylase inhibitors; R-1496; HOB1 modulators;NOX-B11; peptide YY 3-36 (eligen); 5-HT 1 modulators; pancreatic lipaseinhibitors; GRC-1087; CB-1 antagonists; MCH-1 antagonists; LY-448100;bombesin BRS3 agonists; ghrelin antagonists; MC4 antagonists;stearoyl-CoA desaturase modulators; H3 histamine antagonists; PPARpanagonists; EP-01492; hormone-sensitive lipase inhibitors; fattyacid-binding protein 4 inhibitors; thiolactone derivatives; proteintyrosine phosphatase 1B inhibitors; MCH-1 antagonist; P-64; PPAR gammaligands; melanin concentrating hormone antagonists; thiazolegastroprokinetics; PA-452; T-226296; A-331440; immunodrug vaccines;diabetes/obesity therapeutics (Bioagency, Biofrontera Discovery GmbH);P-7 (Genfit); DT-011 M; PTP1B inhibitor; anti-diabetic peptideconjugates; KATP agonists; obesity therapeutics (Lexicon); 5-HT2agonists; MCH-1 receptor antagonists; GMAD-1/GMAD-2; STG-a-MD;neuropeptide Y antagonist; angiogenesis inhibitors; G protein-coupledreceptor agonists; nicotinic therapeutics (ChemGenex); anti-obesityagents (Abbott); neuropeptide Y modulators; melanin concentratinghormone; GW-594884A; MC-4R agonist; histamine H3 antagonists; orphanGPCR modulators; MITO-3108; NLC-002; HE-2300; IGF/IBP-2-13; 5-HT2Cagonists; ML-22952; neuropeptide Y receptor antagonists; AZ-40140;anti-obesity therapy (Nisshin Flour); GNTI; melanocortin receptormodulators; alpha-amylase inhibitors; neuropeptide Yl antagonist; beta-3adrenoceptor agonists; ob gene products (Eli Lilly & Co.); SWR-0342-SA;beta-3 adrenoceptor agonist; SWR-0335; SP-18904; oral insulin mimetics;beta 3 adrenoceptor agonists; NPY-1 antagonists; .beta.-3 agonists;obesity therapeutics (7TM Pharma); 1 lbeta-hydroxysteroid dehydrogenase(HSD)1 inhibitors; QRX-431; E-6776; RI-450; melanocortin-4 antagonists;melanocortin 4 receptor agonists; obesity therapeutics (CuraGen); leptinmimetics; A-74498; second-generation leptin; NBI-103; CL-314698;CP-114271; beta-3 adrenoceptor agonists; NMI 8739; UCL-1283; BMS-192548;CP-94253; PD-160170; nicotinic agonist; LG-100754; SB-226552; LY-355124;CKD-711; L-751250; PPAR inhibitors; G-protein therapeutics; obesitytherapy (Amylin Pharmaceuticals Inc.); BW-1229; monoclonal antibody(ObeSys/CAT); L-742791; (S)sibutramine; MBU-23; YM-268; BTS-78050;tubby-like protein genes; genomics (eating disorders; Allelix/Lilly);MS-706; GT-264879A; GW-409890; FR-79620 analogs; obesity therapy(Hybrigenics SA); ICI-198157; ESP-A; 5-HT2C agonists; PD-170292;AIT-202; LG-100641; GI-181771; anti-obesity therapeutics (Genzyme);leptin modulator; GHRH mimetics; obesity therapy (YamanouchiPharmaceutical Co. Ltd.); SB-251023; CP-331684; BIBO-3304;cholesten-3-ones; LY-362884; BRL-48962; NPY-1 antagonists; A-71378;®-didesmethylsibutramine; amide derivatives; obesity therapeutics(Bristol-Myers Squibb Co.); obesity therapeutics (Ligand PharmaceuticalsInc.); LY-226936; NPY antagonists; CCK-A agonists; FPL-14294; PD-145942;ZA-7114; CL-316243; SR-58878; R-1065; BIBP-3226; HP-228; talibegron;FR-165914; AZM-008; AZM-016; AZM-120; AZM-090; vomeropherin; BMS-187257;D-3800; AZM-131; gene discovery (Axys/Glaxo); BRL-26830A; SX-013; ERRmodulators; adipsin; AC-253; A-71623; A-68552; BMS-210285; TAK-677;MPV-1743; obesity therapeutics (Modex); GI-248573; AZM-134; AZM-127;AZM-083; AZM-132; AZM-115; cxopipam; SSR-125180; obesity therapeutics(Melacure Therapeutics AB); BRL-35135; SR-146131; P-57; AZM-140;CGP-71583A; RF-1051; BMS-196085; manifaxine; beta-3 agonists; DMNJ(Korea Research Institute of Bioscience and Biotechnology); BVT-5182;LY-255582; SNX

024; galanin antagonists; neurokinin-3 antagonists; dexfenfluramine;mazindol; diethylpropion; phendimetrazine; benzphetamine; amfebutmone;sertraline; AOD-9604; ATL-062; BVT-933; GT389-255; SLV319; HE-2500;PEG-axokine; L-796568; and ABT-239.

Formulations

As noted above, the metformin component of the combination dosage formis adapted for delayed release so as to minimize plasma absorption.Delivery may be by any known method including, e.g., oral, rectal,nasogastric tube, parenteral injection such as intraluminal intestinalinjection. In preferred embodiments, the subject combination dosageforms are orally administered. Oral delivery of biguanide compounds isdescribed in the delayed release formulations section and includes timedrelease systems, enteric coatings and pH dependent systems, and thelike. In preferred embodiments, the biguanide compound is delivered toseveral places in the gastrointestinal tract such as the duodenum,jejunum, ileum, lower intestine or combinations thereof followingadministration, while the two or more additional active agents areformulated for immediate- and/or extended release. For example, acombination dosage form comprising the biguanide compound can deliver tothe lower intestine by means of a timed or delayed (enteric) releasecomponent, while the additional active agents are released eitherimmediately upon ingestion. In preferred embodiments, the combinationdosage forms of the present invention are fixed-dose unitary dosageforms such as bi- or tri- or multiple-layer tablets, ormulti-particulate forms such as encapsulated micro-tablets or granules.

In some embodiments, the delayed-release component releases thebiguanide compound after onset of a desired pH, due to the entericcoating. pHs contemplated include about pH 5.0 or about pH 5.5, morepreferably about pH 6.0, about pH 6.5 and about pH 7.0. After onset of adesired pH, the compound begins release. Such compositions may releasethe biguanide compound in about 15 minutes, about 20 minutes, about 25minutes or about 30 minutes after the onset of the desired pH, and/ormay have timed, extended or slow release aspects that release thebiguanide compound over the course of a longer time period such as about1 hour, about 2 hours, about 3 hours, about 4 hours, about 5 hours,about 6 hours, about 7 hours or about 8 hours. Exemplary two componentdelivery system can be, in some embodiments, a bilayer or trilayertablet. Three, four and additional components are contemplated withinthe embodiments.

For delayed-release formulations comprising the biguanide compound,dosages of the compound can range from about 1 mg to about 1000 mg,about 10 mg to about 950 mg, about 50 mg to about 900 mg or about 100 mgor about 800 mg per day. In some instances, the dosage of the compoundis about 800 mg, about 700, about 600 mg, about 500 mg, about 400 mg,about 300 mg, about 250 mg, about 200 mg, about 150 mg, about 100 mg,about 75 mg, about 50 mg, about 25 mg, about 10 mg or about 1 mg perday. In some embodiments, the dosage of the compound is less than 400mg. In some embodiments, the dosage of the compound is 250 mg.

Salts of biguanide compound include, but are not limited to,hydrochloride, phosphate, sulfate, hydrobromide, salicylate, maleate,benzoate, succinnate, ethanesulfonate, fumarate, glycolate, pamoate,oratate, acetate, isobutyrate, acetylsalicylate, nicotinic acid,adamantoate, zinc chlorophylin, carboxylic acid, benzoic acid,dichloroacetic acid, theophylin-7-acetate, clofibrate, tartate, oxalate,tannate and hydroxyl acid salts. In preferred embodiment, the salt ismetformin hydrochloride.

Formulations for the compositions provided herein include those suitablefor oral or rectal administration, although the most suitable route candepend upon for example the condition and disorder of the recipient. Thecompositions are preferably presented in unitary fixed-dosage form andcan be prepared by any of the methods well known in the art of pharmacy.All methods include the step of bringing into association the activeingredient with the carrier which constitutes one or more accessoryingredients.

Formulations suitable for oral administration can be presented asdiscrete units such as capsules, cachets or tablets each containing apredetermined amount of the active ingredient; as a powder or granules;as a solution or a suspension in an aqueous liquid or a non-aqueousliquid; or as an oil-in-water liquid emulsion or a water-in-oil liquidemulsion.

Composition preparations which can be used orally include tablets,push-fit capsules made of gelatin, as well as soft, sealed capsules madeof gelatin and a plasticizer, such as glycerol or sorbitol. Tablets canbe made by compression or molding, optionally with one or more accessoryingredients. Compressed tablets can be prepared by compressing in asuitable machine the active ingredient in a free-flowing form such as apowder or granules, optionally mixed with binders (e.g., povidone,gelatin, hydroxypropylmethyl cellulose), inert diluents, preservative,disintegrant (e.g., sodium starch glycolate, cross-linked povidone,cross-linked sodium carboxymethyl cellulose) or lubricating, surfaceactive or dispersing agents. Molded tablets can be made by molding in asuitable machine a mixture of the powdered compound moistened with aninert liquid diluent. The tablets can optionally be coated or scored andcan be formulated so as to provide slow or controlled release of theactive ingredient therein. Tablets can optionally be provided with anenteric coating, to provide release in parts of the gut other than thestomach. All formulations for oral administration should be in dosagessuitable for such administration. The push-fit capsules can contain theactive ingredients in admixture with filler such as lactose, binderssuch as starches, and/or lubricants such as talc or magnesium stearateand, optionally, stabilizers. In soft capsules, the active compounds canbe dissolved or suspended in suitable liquids, such as fatty oils,liquid paraffin, or liquid polyethylene glycols. In addition,stabilizers can be added. Dragee cores are provided with suitablecoatings. For this purpose, concentrated sugar solutions can be used,which can optionally contain gum arabic, talc, polyvinyl pyrrolidone,carbopol gel, polyethylene glycol, and/or titanium dioxide, lacquersolutions, and suitable organic solvents or solvent mixtures. Dyestuffsor pigments can be added to the tablets or Dragee coatings foridentification or to characterize different combinations of activecompound doses.

It should be understood that in addition to the ingredients particularlymentioned above, the compounds and compositions described herein caninclude other agents conventional in the art having regard to the typeof formulation in question, for example those suitable for oraladministration can include flavoring agents.

The compositions described herein can also contain the biguanidecompound in a form suitable for oral use, for example, as tablets,troches, lozenges, aqueous or oily suspensions, dispersible powders orgranules, emulsions, hard or soft capsules, or syrups or elixirs.Compositions intended for oral use can be prepared according to anymethod known to the art for the manufacture of pharmaceuticalcompositions, and such compositions can contain one or more agentsselected from, by way of non-limiting example, sweetening agents,flavoring agents, coloring agents and preserving agents in order toprovide pharmaceutically elegant and palatable preparations.

Delayed Release Formulations

Many strategies can be pursued to obtain delayed release in which thelocation of the release is controlled so as to minimize systemicabsorption. For example, delayed release can be obtained by theappropriate selection of formulation parameters and ingredients (e.g.,appropriate controlled release compositions and coatings). Examplesinclude single or multiple unit tablet or capsule compositions, oilsolutions, suspensions, emulsions, microcapsules, microspheres,nanoparticles and liposomes. The release mechanism can be controlledsuch that the biguanide compounds are released at period intervals orthe location of the release is controlled, the release of combinedagents can be simultaneous, or a delayed release of the biguanidecompound in a combination can be affected when the early release ofanother combined therapeutic one is preferred over the other. Differentdelivery systems described herein can also be combined to release at anonset of multiple period intervals (e.g., about 30 minutes, about 120minutes, about 180 minutes and about 240 minutes after oraladministration) or at different locations (e.g., release in the lowerintestine, upper intestine, the jejunum, ileum, caecum, colon, and/orrectum) or a combination thereof. For example, a pH dependent system canbe combined with a timed release system or any other system describedherein to achieve a desired release profile.

In preferred embodiments, the biguanide compounds are formulated as adelayed release component coupled with an immediate- and/or extendedrelease component of two or more additional active agents in a unitarydosage form. The immediate release component can be formulated by anyknown method such as a layer that envelops a portion of the delayedrelease component or the like. Exemplary ratios of immediate release ofan additional therapeutic agent to delayed release of a biguanidecompound are about 10% IR to about 90% DR, about 15% IR to about 85% DR,about 20% IR to about 80% DR, about 25% IR to about 75% DR, about 30% IRto about 70% DR, about 35% IR to about 65% DR, about 40% IR to about 60%DR, about 45% IR to about 55% DR, or about 50% IR to about 50% DR. Incertain embodiments, the immediate release of an active agent to delayedrelease of an active agent is about 25% IR to about 75% DR. In certainembodiments, the immediate release of an active agent to delayed releaseof an active agent is about 20% IR to about 80% DR. Unitary dosage formswith an IR and DR component include any known formulation includingbilayer tablets, coated pellets, and the like.

Timed Release Systems

In one embodiment, the delayed-release mechanism is a “timed” ortemporal release (“TR”) system that releases an active agent, forexample a biguanide compound, at certain timepoints subsequent toadministration. Timed release systems are well known in the art andsuitable timed release systems can include any known excipient and/orcoating. For example, excipients in a matrix, layer or coating can delayrelease of an active agent by slowing diffusion of the active agent intoan environment. Suitable timed release excipients include but are notlimited to, acacia (gum arabic), agar, aluminum magnesium silicate,alginates (sodium alginate), sodium stearate, bladderwrack, bentonite,carbomer, carrageenan, Carbopol, cellulose, microcrystalline cellulose,ceratonia, chondrus, dextrose, furcellaran, gelatin, Ghatti gum, guargum, galactomannan, hectorite, lactose, sucrose, maltodextrin, mannitol,sorbitol, honey, maize starch, wheat starch, rice starch, potato starch,gelatin, sterculia gum, xanthum gum, Glyceryl behenate (e.g., Compritol888 ato), Gylceryl distearate (e.g. Precirol ato 5), polyethylene glycol(e.g., PEG 200-4500), polyethylene oxide, adipic acid, gum tragacanth,ethyl cellulose (e.g., ethyl cellulose 100), ethylhydroxyethylcellulose, ethylmethyl cellulose, methyl cellulose, hydroxyethylcellulose, hydroxyethylmethyl cellulose (e.g., K1OOLV, K4M, K15M),hydroxypropyl cellulose, poly(hydroxyethyl methacrylate), celluloseacetate (e.g. cellulose acetate CA-398-10 NF), cellulose acetatephthalate, cellulose acetate propionate, cellulose acetate butyrate,hydroxypropyl methyl cellulose acetate succinate, hydroxypropyl methylcellulose phthalate, cellulose butyrate, cellulose nitrate,oxypolygelatin, pectin, polygeline, povidone, propylene carbonate,polyandrides, methyl vinyl ether/maleic anhydride copolymer (PVM/MA),poly(mcthoxycthyl methacrylate), poly(mcthoxycthoxycthyl methacrylate),hydroxypropyl cellulose, hydroxypropylmethyl cellulose, sodiumcarboxymethyl-cellulose (CMC), silicon dioxide, vinyl polymers, e.g.polyvinyl pyrrolidones(PVP: povidone), polyvinyl acetates, or polyvinylacetate phthalates and mixtures, Kollidon SR, acryl derivatives (e.g.polyacrylates, e.g. cross-linked polyacrylates, methycrylic acidcopolymers), Splenda® (dextrose, maltodextrin and sucralose) orcombinations thereof. The timed release excipient may be in a matrixwith active agent, in another compartment or layer of the formulation,as part of the coating, or any combination thereof. Varying amounts ofone or more timed release excipients may be used to achieve a designatedrelease time.

One non-limiting example includes formulations of the T1MERx® system.This controlled release formulation system provides for altered temporalrelease (SyncroDose™) as well as biphasic release (Geminex®). (See, forexample, Staniforth & Baichwal, TIMERx®: novel polysaccharide compositesfor controlled/programmed release of active ingredients in thegastrointestinal tract, Expert Opin. Drug Deliv., 2(3): 587-89 (2005)).Using formulations such as these for the invention described herein,compositions can be created which target the upper gastrointestinaltract, the lower gastrointestinal tract, or both, in addition totemporally controlling the release of such compounds in any of theselocations.

In some embodiments, the timed release systems are formulated to releasethe compound at an onset of about 5 minutes, about 10 minutes, about 20minutes, about 30 minutes, about 40 minutes, about 50 minutes, about 60minutes, about 70 minutes, about 80 minutes, about 90 minutes, about 100minutes, about 110 minutes, about 120 minutes, about 130 minutes, about140 minutes, about 150 minutes, about 160 minutes, about 170 minutes,about 180 minutes, about 190 minutes, about 200 minutes, about 210minutes, about 220 minutes, about 230 minutes, about 240 minutes, about250 minutes, about 260 minutes, about 270 minutes, about 280 minutes,about 290 minutes, about 300 minutes, about 310 minutes, about 320minutes, about 330 minutes, about 340 minutes, about 350 minutes, about360 minutes, about 370 minutes, about 380 minutes, about 390 minutes,about 400, about 400, about 410, or about 420 minutes subsequent toadministration. In embodiments with multiple releases, timed releasesystems are formulated to release at more than one time point. Incertain embodiments, the timed release systems are formulated to releaseat an onset of about 10 minutes, about 30 minutes, about 120 minutes,about 180 minutes and about 240 minutes after administration. In certainembodiments the timed release systems arc formulated to release at anonset of about 5 to about 45 minutes, about 105 to about 135 minutes,about 165 to about 195 minutes, about 225 to about 255 minutes or acombination of times thereof following administration to a patient.

Enteric Coatings and pH Dependent Systems

The formulation may also be coated with an enteric coating, whichprotects an active agent, for example a biguanide compound, fromdegradation in an acidic environment, such as the stomach, and allows adelayed release into a target area, for example the ileum, for uptake.

The enteric coating may be, as a non-limiting example, wax or wax likesubstance, such as carnauba wax, fatty alcohols, hydrogenated vegetableoils, zein, shellac, sucrose, Arabic gum, gelatin, dextrin, psylliumhusk powder, polymethacrylates, anionic polymethacrylates, mixtures ofpoly(methacrylic acid, methyl methacrylate), polymers or copolymersderived from acrylic and/or methacrylic acid esters, cellulose acetatephthalate, cellulose acetate trimelliate, hydroxypropyl methylcellulosephthalate (HPMCP), cellulose propionate phthalate, cellulose acetatemaleate, polyvinyl alcohol phthalate, hydroxypropyl methylcelluloseacetate succinate (HPMCAS), hydroxypropyl methylcellulosehexahydrophthalate, polyvinyl acetate phthalate, mixtures ofpoly(methacrylic acid, ethyl acrylate), ethylcellulose, methylcellulose,propylcellulose, chitosan succinate, chitosan succinate, polyvinylacetate phthalate (PVAP), polyvinyl acetate polymers carboxymethylethylcellulose and compatible mixtures thereof. In addition, an inactiveintermediate film may be provided between the biguanide compound, andthe enteric coating to prevent interaction of the biguanide compoundwith the enteric coating.

In one non-limiting example, silicone microspheres for pH-controlledgastrointestinal drug delivery have been described by Carelli et al.,Int. J. Pharmaceutics 179: 73-83, 1999. The microspheres arepH-sensitive semi-interpenetrating polymer hydrogels made of varyingproportions of poly(methacrylic acid-co-methylmethacrylate) (EUDRAGIT®L100 or EUDRAGIT® S100) and crosslinked polyethylene glycol 8000 thatare encapsulated into silicone microspheres. The EUDRAGIT® series ofmethacrylic acid copolymers are commercially available from EvonikIndustries in Darmstadt, Germany.

The enteric coatings can be formulated to release a biguanide compoundat a desired pH using combinations of enteric polymers. It is well-knownthat different locations of the gastrointestinal system have specificpHs. For example, the duodenum may correspond to a pH 5.5 environmentand the jejunum may correspond to pH 6.0 environment. In preferredembodiments, the enteric coatings arc formulated to release the compoundat an onset of a desired pH, e.g., in the distal small intestine andlower intestine, i.e., at about pH 6, about pH 6.5, or about pH 7. Inembodiments with multiple releases, the enteric coatings are formulatedto release at an onset of two or more pH values. In certain embodiments,the enteric coatings are formulated to release at an onset of pH 6.0,6.5 and 7.0. In certain embodiments, the enteric coatings are formulatedto release at an onset of pH 6.5 and 7.0. In certain embodiments, theenteric coatings are formulated to release at the jejunum, ileum, andlower intestine. In yet other embodiments, the enteric coatings are usedin combination with other release systems such as a timed releasesystem.

In yet other embodiments, the enteric coatings are used in combinationwith an immediate release/extended release unitary dosage form. Forexample, a unitary dosage form, such as a bilayer tablet with a 20%IR/80% MR component of the biguanide compound can be coated with anenteric coating that releases at pH, e.g., 5.5, 6.0, 6.5, 7.0 so thatthe release is delayed until the dosage form reaches a pH of e.g., 5.5,6.0, 6.5, 7.0 thereby releasing the IR component immediately and the MRcomponent according to its MR release properties. In certain instances,the enteric coatings are used in combination with an immediaterelease/timed release unitary dosage forms.

The microcapsules gastroretentive systems described in U.S. Pat. Nos.6,022,562, 5,846,566 and 5,603,957, can be used in the delayed releasedelivery methods described herein. Microparticles of an active agent ordrug are coated by spraying with a material consisting of a mixture of afilm-forming polymer derivative, a hydrophobic plasticizer, a functionalagent and a nitrogen-containing polymer. The resulting microcapsules areless than or equal to 1000 microns (gm) in size, and in certain casessuch microcapsules arc between 100 and 500 microns. These microcapsulesremain in the small intestine for at least 5 hours.

Film-forming polymer derivatives used in such microcapsules include, butare not limited to, ethylcellulose, cellulose acetate, andnon-hydrosoluble cellulose derivates. The nitrogen-containing polymersinclude, but are not limited to, polyacrylamide, poly-N-vinylamide,poly-N-vinyl-lactam and polyvinylpyrrolidone. The plasticizer used insuch microcapsule include, but are not limited to, glycerol esters,phthalates, citrates, sebacates, cetylalcohol esters, castor oil andcutin. The surface-active and/or lubricating agent used in suchmicrocapsule include, but arc not limited to, anionic surfactants, suchas by way of example the alkali metal or alkaline-earth metal salts offatty acids, stearic acid and/or oleic acid, nonionic surfactants, suchas by way of example, polyoxyethylenated esters of sorbitan and/orpolyoxyethylenated esters of sorbitan and/or polyoxyethylenatedderivatives of castor oil; and/or lubricants such as stearates, such asby way of example, calcium, magnesium, aluminum stearate, zinc stearate,stearylfumarate, sodium stearylfimarate, and glyceryl behenate.

One non-limiting example of a lower GI delivery formulation comprises atablet for lower GI delivery. The inner composition of the tabletcomprises about 0.01% weight to about 10.0% by weight of a suitableactive ingredient; about 50% by weight to about 98% by weight of ahydrocolloid gum obtainable from higher plants; and about 2% by weightto about 50% by weight of a pharmaceutically acceptable excipient suchas a binder. Other optional materials may be present that will assist inestablishing the desired characteristics of the pharmaceuticalcomposition. These include materials that may enhance absorption of theactive ingredient in the lower GI, may protect the active ingredientagainst degradation, may prevent dissolution, and the like. Optionallysurrounding the inner composition of the tablet is a coating that ispreferably of enteric polymeric material.

The formulation is designed to take advantage of (1) the protectivecharacteristics of the hydrocolloid obtainable from higher plants in theupper GI and (2) the disintegrative characteristics of the hydrocolloidin the lower GI. Thus, the inner composition of the tablet may be one ofseveral designs: (a) it may be a matrix of a therapeutically effectiveamount of the active ingredient uniformly dispersed throughout incombination with a high percentage of the hydrocolloid and a generallylesser amount of other excipients; (b) it may have a core, in which theactive ingredient is concentrated, surrounded by a layer of materialthat is free of the active ingredient and that has a high percentage ofthe hydrocolloid and a generally lesser amount of other excipients; (c)it may have a concentration gradient of the active ingredient such thatthere is a greater amount in the core of the tablet with lesser amountsin multiple layers surrounding the core and very little or no activeingredient in the outer layer. Whether the design of the tablet is thatof (a), (b) or (c) above, the specificity for regional delivery to thelower GI is enhanced by enterically coating the tablet with anappropriate enteric coating material.

Suitable hydrocolloids arc well known in the art. See for example “TheChemistry of Plant Gums and Mucilages” by Smith and Montgomery from theA.C.S. Monograph series, #141, 1959, Reinhold Publishing Co. and theEighteenth Edition of The Merck Index. In general, the amount of thehydrocolloid that will be used is an amount that allows the compositionto traverse the upper GI tract without significant disintegration andwithout releasing significant amounts of active ingredient in the upperGI tract, i.e. to provide a delayed-release profile. Generally, thatamount of hydrocolloid will be more than about 50% but less than about98%. Depending on individual variability, whether a patient has eaten orhas fasted, and other factors, a tablet will traverse the stomach andupper intestinal tract in about 3 to 6 hours. During this time, littleactive ingredient (less than 20%, preferably less than 10%) is releasedfrom the tablet of this invention. Once the tablet reaches the lower GI,the release of the active ingredient is triggered by enzymaticdegradation of the galactomannan gum.

Modified Release Formulations

In additional embodiment, the methods and compositions directed tobiguanide compound delivery may further employ controlled, sustained, orextended release formulations known collectively as “modified release”formulations. Compositions can be administered by modified releasesystems or by delivery devices that are well known to those of ordinaryskill in the art. Examples include, but are not limited to, thosedescribed in U.S. Pat. Nos. 3,845,770; 3,916,899; 3,536,809; 3,598,123;4,008,719; 5,674,533; 5,059,595; 5,591,767; 5,120,548; 5,073,543;5,639,476; 5,354,556; and 5,733,566. Such dosage forms can be used toprovide modified release of one or more active ingredients using, forexample, hydropropylmethyl cellulose, other polymer matrices, gels,permeable membranes, osmotic systems, multilayer coatings,microparticles, liposomes, microspheres, or a combination thereof toprovide the desired release profile in varying proportions. Suitablemodified release formulations known to those of ordinary skill in theart, including those described herein, can be readily selected for usewith the active ingredients of the invention. The invention thusencompasses single unit dosage forms suitable for oral administrationsuch as, but not limited to, tablets, capsules, gelcaps, and capletsthat are further adapted for modified release.

In some embodiments, the modified release systems are formulated torelease the compound at a duration of about 30 minutes, about 40minutes, about 50 minutes, about 60 minutes, about 70 minutes, about 80minutes, about 90 minutes, about 100 minutes, about 110 minutes, about120 minutes, about 130 minutes, about 140 minutes, about 150 minutes,about 160 minutes, about 170 minutes, about 180 minutes, about 190minutes, about 200 minutes, about 210 minutes, about 220 minutes, about230 minutes, about 240 minutes, about 250 minutes, about 260 minutes,about 270 minutes, about 280 minutes, about 290 minutes, about 300minutes, about 310 minutes, about 320 minutes, about 330 minutes, about340 minutes, about 350 minutes, about 360 minutes, about 370 minutes,about 380 minutes, about 390 minutes, about 400, about 400, about 410,or about 420 minutes subsequent to onset of the release. In embodimentswith multiple releases, modified release systems are formulated torelease at more than one durations of time at different time points.

In one non-limiting example, chitosan and mixtures of chitosan withcarboxymethylcellulose sodium (CMC-Na) have been used as vehicles forthe sustained release of active ingredients, as described by Inouye etal., Drug Design and Delivery 1: 297-305, 1987. Mixtures of thesecompounds and agents of the combinations of the invention, whencompressed under 200 kg/cm2, form a tablet from which the active agentis slowly released upon administration to a patient. The release profilecan be changed by varying the ratios of chitosan, CMC-Na, and activeagent(s). The tablets can also contain other additives, includinglactose, CaHPO4 dihydrate, sucrose, crystalline cellulose, orcroscarmellose sodium.

In another non-limiting example, Baichwal, in U.S. Pat. No. 6,245,356,describes sustained release oral, solid dosage forms that includeagglomerated particles of a therapeutically active medicament inamorphous form, a gelling agent, an ionizable gel strength enhancingagent and an inert diluent. The gelling agent can be a mixture of axanthan gum and a locust bean gum capable of cross-linking with thexanthan gum when the gums are exposed to an environmental fluid.Preferably, the ionizable gel enhancing agent acts to enhance thestrength of cross-linking between the xanthan gum and the locust beangum and thereby prolonging the release of the medicament component ofthe formulation. In addition to xanthan gum and locust bean gum,acceptable gelling agents that may also be used include those gellingagents well known in the art. Examples include naturally occurring ormodified naturally occurring gums such as alginates, carrageenan,pectin, guar gum, modified starch, hydroxypropylmethylcellulose,methylcellulose, and other cellulosic materials or polymers, such as,for example, sodium carboxymethylcellulose and hydroxypropyl cellulose,and mixtures of the foregoing.

In another non-limiting formulation useful for the combinations of theinvention, Baichwal and Staniforth in U.S. Pat. No. 5,135,757 describe afree-flowing slow release granulation for use as a pharmaceuticalexcipient that includes from about 20 to about 70 percent or more byweight of a hydrophilic material that includes a heteropolysaccharide(such as, for example, xanthan gum or a derivative thereof) and apolysaccharide material capable of cross-linking theheteropolysaccharide (such as, for example, galactomannans, and mostpreferably locust bean gum) in the presence of aqueous solutions, andfrom about 30 to about 80 percent by weight of an inertpharmaceutical-filler (such as, for example, lactose, dextrose, sucrose,sorbitol, xylitol, fructose or mixtures thereof). After mixing theexcipient with a tricyclic compound/corticosteroid combination, orcombination agent, of the invention, the mixture is directly compressedinto solid dosage forms such as tablets. The tablets thus formed slowlyrelease the medicament when ingested and exposed to gastric fluids. Byvarying the amount of excipient relative to the medicament, a slowrelease profile can be attained.

Slow-release formulations can also include a coating which is notreadily water-soluble but which is slowly attacked and removed by water,or through which water can slowly permeate. Thus, for example, thecombinations of the invention can be spray-coated with a solution of abinder under continuously fluidizing conditions, such as describe byKitamori et al., U.S. Pat. No. 4,036,948. Examples of water-solublebinders include pregelatinized starch (e.g., pregelatinized corn starch,pregelatinized white potato starch), pregelatinized modified starch,water-soluble celluloses (e.g. hydroxypropyl-cellulose,hydroxymethyl-cellulose, hydroxypropylmethyl-cellulose,carboxymethyl-cellulose), polyvinylpyrrolidone, polyvinyl alcohol,dextrin, gum arabicum and gelatin, organic solvent-soluble binders, suchas cellulose derivatives (e.g., cellulose acetate phthalate,hydroxypropylmethyl-cellulose phthalate, ethylcellulose).

In another non-limiting example, Villa et al., in U.S. Pat. No.6,773,720, describes a modified-release system containing an innerlipophilic matrix where an active ingredient is inglobated and an outerhydrophilic matrix in which the lipophilic matrix is dispersed. Anactive ingredient, such as a biguanide or related heterocyclic compound,is first inglobated in a low melting lipophlilic excipient or mixture ofexcipients while heating to soften and/or melt the excipient itself,which thereby incorporates the active ingredient by simple dispersion.After cooling at room temperature, an inert matrix forms, which can bereduced in size to obtain matrix granules containing the activeingredient particles. The inert matrix granules are subsequently mixedtogether with one or more hydrophilic water-swellable excipients. Inthis respect, when the composition is contacted with biological fluids,a high viscosity swollen layer is formed, which coordinates the solventmolecules and acts as a barrier to penetration of the aqueous fluiditself inside the new structure. Said barrier antagonizes the staring“burst effect” caused by dissolution of the active ingredient inglobatedinside the inert matrix, which is in its turn inside the hydrophilicmatrix. One commercially available system of this type is from CosmoTechnologies Limited (Italy) under the trade name MMX® technology. Thelipophilic/hydrophilic matrices can be further enterically coated for pHspecific delivery.

Formulations for upper intestinal delivery, lower intestinal delivery orboth are known in the art. Targeting of active ingredients to variousregions of the gut is described, e.g., in The Encyclopedia ofPharmaceutical Technology, by James Swarbrick and James Boylan, InformaHealth Care, 1999, at pp. 287-308. Any suitable formulation forgastrointestinal delivery for site-specific delivery and/or specifictemporal delivery (i.e. delayed, controlled, extended, or sustainedrelease) can be used with the invention and is contemplated herein.

Any of the delivery systems described herein may be used in combinationwith others to achieve multiple releases and/or specific releaseprofiles. In some embodiments, the biguanide compound is in aformulation that achieves multiple releases in gastrointestinallocations following administration. In certain embodiments, thebiguanide compound is in a multiple release formulation that releases atan onset of about 10 minutes, about 30 minutes, about 120 minutes, about180 minutes, about 240 minutes, or combinations thereof followingadministration. In certain embodiments, the biguanide compound is in amultiple release formulation that releases at an onset of about 5 toabout 45 minutes, about 105 to about 135 minutes, about 165 to about 195minutes, about 225 to about 255 minutes, or combinations thereoffollowing administration.

In certain embodiments, the biguanide compound is in a multiple releaseformulation that releases in the duodenum, jejunum, ileum, lowerintestine or combinations thereof following administration. In yet otherembodiments, the biguanide compound is in a multiple release formulationthat releases at an onset of about pH 5.5, about pH 6.0, at about pH6.5, about pH 7.0, or combinations thereof following administration. Inyet other embodiments, the biguanide compound is in a multiple releaseformulation that releases in ranges at about pH 5.0 to about pH 6.0,about pH 6.0 to about pH 7.0, about pH 7.0 to about pH 8.0, orcombinations thereof following administration. In yet other embodiments,the biguanide compound is in a multiple release formulation thatreleases a fraction or portion of the biguanide as an immediate releasewith the rest of the compound released in a delayed manner as describedherein.

Oral Dosage Forms

Oral dosage forms suitable for use in the subject compositions andmethods include tablets, hard capsules, push-fit capsules made ofgelatin, as well as soft, sealed capsules made of gelatin and aplasticizer, such as glycerol or sorbitol, as well as troches, lozenges,aqueous or oily suspensions, dispersible powders or granules, emulsions,syrups or elixirs. Suitable oral dosage forms can be prepared accordingto any method known to the art for the manufacture of pharmaceuticalcompositions, and such compositions can contain one or more agentsselected from, by way of non-limiting example, sweetening agents,flavoring agents, coloring agents and preserving agents in order toprovide pharmaceutically elegant and palatable preparations.

Tablets contain the active ingredient in admixture with pharmaceuticallyacceptable excipients which are suitable for the manufacture of tablets.These excipients can be, for example, inert diluents, such as calciumcarbonate, sodium carbonate, lactose, calcium phosphate or sodiumphosphate; granulating and disintegrating agents, such asmicrocrystalline cellulose, sodium crosscarmellose, corn starch, oralginic acid; binding agents, for example starch, gelatin,polyvinyl-pyrrolidone or acacia, and lubricating agents, for example,magnesium stearate, stearic acid or talc. Tablets can be made bycompression or molding, optionally with one or more accessoryingredients. Compressed tablets can be prepared by compressing in asuitable machine the active ingredient in a free-flowing form such as apowder or granules, optionally mixed with binders (e.g., povidone,gelatin, hydroxypropylmethylcellulose), inert diluents, preservatives,disintegrants (e.g., sodium starch glycolate, cross-linked povidone,cross-linked sodium carboxymethyl cellulose) or lubricating, surfaceactive or dispersing agents. Molded tablets can be made by molding in asuitable machine a mixture of the powdered compound moistened with aninert liquid diluent. The tablets are coated by known techniques todelay disintegration and absorption in the gastrointestinal tract andthereby minimize systemic bioavailability as described more fullyherein.

Formulations for oral use can also be presented as hard gelatin capsuleswherein the active ingredient is mixed with an inert solid diluent, forexample, calcium carbonate, calcium phosphate or kaolin, or as softgelatin capsules wherein the active ingredient is mixed with watersoluble carrier such as polyethyleneglycol or an oil medium, for examplepeanut oil, liquid paraffin, or olive oil. Alternatively, push-fitcapsules can contain the active ingredients in admixture with fillersuch as lactose, binders such as starches, and/or lubricants such astalc or magnesium stearate and, optionally, stabilizers. In softcapsules, the active compounds can be dissolved or suspended in suitableliquids, such as fatty oils, liquid paraffin, or liquid polyethyleneglycols. In addition, stabilizers can be added. Dragee cores areprovided with suitable coatings. For this purpose, concentrated sugarsolutions can be used, which can optionally contain gum arabic, talc,polyvinyl pyrrolidone, carbopol gel, polyethylene glycol, and/ortitanium dioxide, lacquer solutions, and suitable organic solvents orsolvent mixtures. Dyestuffs or pigments can be added to the tablets orDragee coatings for identification or to characterize differentcombinations of active compound doses.

It should be understood that in addition to the ingredients particularlymentioned above, the compounds and compositions described herein caninclude other agents conventional in the art having regard to the typeof formulation in question, for example those suitable for oraladministration can include flavoring agents.

In various embodiments, the compositions provided herein are in liquidform. Liquid forms include, by way of non-limiting example, neatliquids, solutions, suspensions, dispersions, colloids, foams and thelike. In certain instances, liquid forms contain also a nutritionalcomponent or base (e.g., derived from milk, yogurt, shake, or juice). Insome aspects, the compound are micronized or as nanoparticles in theliquid form. In certain instances, the compounds may be coated to maskthe tastant properties. In other instances, the compounds are coated tomodify delivery to the intestine and colon.

Aqueous solutions or suspensions contain the active ingredient(s) inadmixture with excipients suitable for the manufacture of aqueoussuspensions. Such excipients are suspending agents, for example sodiumcarboxymethylcellulose, methylcellulose, hydroxypropylmethyl

cellulose, sodium alginate, polyvinyl-pyrrolidone, gum tragacanth andgum acacia; dispersing or wetting agents can be a naturally-occurringphosphatide, for example lecithin, or condensation products of analkylene oxide with fatty acids, for example polyoxyethylene stearate,or condensation products of ethylene oxide with long chain aliphaticalcohols, for example heptadecaethylene-oxycetanol, or condensationproducts of ethylene oxide with partial esters derived from fatty acidsand a hexitol such as polyoxyethylene sorbitol monooleate, orcondensation products of ethylene oxide with partial esters derived fromfatty acids and hexitol anhydrides, for example polyethylene sorbitanmonooleate. The aqueous solutions or suspensions can also contain one ormore preservatives, for example ethyl, or n-propyl p-hydroxybenzoate,one or more coloring agents, one or more flavoring agents, and one ormore sweetening agents, such as sucrose, saccharin or aspartame. Incertain instances, the flavoring agents are the compounds.

Oily suspensions can be formulated by suspending the activeingredient(s) in a vegetable oil, for example arachis oil, olive oil,sesame oil or coconut oil, or in mineral oil such as liquid paraffin.The oily suspensions can contain a thickening agent, for examplebeeswax, hard paraffin or cetyl alcohol. Sweetening agents such as thoseset forth above, and flavoring agents can be added to provide apalatable oral preparation. These compositions can be preserved by theaddition of an antioxidant such as butylated hydroxyanisol oralpha-tocopherol.

Dispersible powders and granules suitable for preparation of an aqueoussolutions or suspension by the addition of water provide the activeingredient in admixture with a dispersing or wetting agent, suspendingagent and one or more preservatives. Suitable dispersing or wettingagents and suspending agents are exemplified by those already mentionedabove. Additional excipients, for example sweetening, flavoring andcoloring agents, can also be present. These compositions can bepreserved by the addition of an antioxidant such as ascorbic acid.

Compositions can also be in the form of an oil-in-water emulsion. Theoily phase can be a vegetable oil, for example olive oil or arachis oil,or a mineral oil, for example liquid paraffin or mixtures of these.Suitable emulsifying agents can be naturally-occurring phosphatides, forexample soy bean lecithin, and esters or partial esters derived fromfatty acids and hexitol anhydrides, for example sorbitan monooleate, andcondensation products of the said partial esters with ethylene oxide,for example polyoxyethylene sorbitan monooleate. The emulsions can alsocontain sweetening agents, flavoring agents, preservatives andantioxidants.

Syrups and elixirs can be formulated with sweetening agents, for exampleglycerol, propylene glycol, sorbitol or sucrose. Such formulations canalso contain a demulcent, a preservative, flavoring and coloring agentsand antioxidant.

Compositions can also be formulated in rectal compositions such assuppositories or retention enemas, e.g., containing conventionalsuppository bases such as cocoa butter, polyethylene glycol, or otherglycerides. These compositions can be prepared by mixing the inhibitorswith a suitable non-irritating excipient which is solid at ordinarytemperatures but liquid at the rectal temperature and will thereforemelt in the rectum to release the drug. Such materials include cocoabutter, glycerinated gelatin, hydrogenated vegetable oils, mixtures ofpolyethylene glycols of various molecular weights and fatty acid estersof polyethylene glycol.

Accordingly, pharmaceutical compositions are also provided comprisingthe biguanide compound in a delayed-release formulation suitable fororal administration such as a tablet, capsule, cachet, pill, lozenge,powder or granule, solution, liquid, or suspension. The pharmaceuticalcomposition is preferably in a unit dosage form suitable for singleadministration of precise dosages, e.g., 100 mg, 200 mg, 250, mg, 300mg, 400 mg, 500 mg, 600 mg, 750 mg, 800 mg, or 1000 mg of the desiredbiguanide compound, particularly metformin, phenformin, buformin orimeglimin or a salt thereof. The pharmaceutical composition may compriseconventional pharmaceutical carriers or excipients and the biguanidecompound according to the invention as an active ingredient. They mayfurther comprise other medicinal or pharmaceutical agents, carriers,adjuvants, etc.

Suitable carriers include inert diluents or fillers, water and variousorganic solvents. The compositions can, if desired, contain additionalingredients such as flavorings, binders, excipients and the like. Thusfor oral administration, tablets containing various excipients, such ascitric acid can be employed together with various disintegrants such asstarch or other cellulosic material, alginic acid and certain complexsilicates and with binding agents such as sucrose, gelatin and acacia.Additionally, lubricating agents such as magnesium stearate, sodiumlauryl sulfate and talc are often useful for tableting purposes. Otherreagents such as an inhibitor, surfactant or solubilizer, plasticizer,stabilizer, viscosity increasing agent, or film forming agent can alsobe added. Solid compositions of a similar type can also be employed insoft and hard filled gelatin capsules. Materials include lactose or milksugar and high molecular weight polyethylene glycols. When aqueoussuspensions or elixirs are desired for oral administration the activecompound therein can be combined with various sweetening or flavoringagents, coloring matters or dyes and, if desired, emulsifying agents orsuspending agents, together with diluents such as water, ethanol,propylene glycol, glycerin, or combinations thereof.

Excipients

Any of the compositions or formulations described herein include anycommonly used excipients in pharmaceutics and are selected on the basisof compatibility with the active agent(s) and release profile propertiesof the desired dosage form. Excipients include, but are not limited to,binders, fillers, flow aids/glidents, disintegrants, lubricants,stabilizers, surfactants, and the like. A summary of excipientsdescribed herein, may be found, for example in Remington: The Scienceand Practice of Pharmacy, Nineteeth Ed (Easton, Pa.: Mack PublishingCompany, 1995); Hoover, John E., Remington's Pharmaceutical Sciences,(Easton, Pa.: Mack Publishing Co 1975); Liberman, H. A. and Lachman, L.,Eds., Pharmaceutical Dosage Forms (New York, N.Y.: Marcel Decker 1980);and Pharmaceutical Dosage Forms and Drug Delivery Systems, Seventh Ed(Lippincott Williams & Wilkins 1999), herein incorporated by referencein their entirety.

Binders impart cohesive qualities and include, e.g., alginic acid andsalts thereof; cellulose derivatives such as carboxymethylcellulose,methylcellulose (e.g., Methocel®), hydroxypropylmethylcellulose,hydroxyethylcellulose, hydroxypropylcellulose (e.g., Klucel®),ethylcellulose (e.g., Ethocel®), and microcrystalline cellulose (e.g.,Avicel®); microcrystalline dextrose; amylose; magnesium aluminumsilicate; polysaccharide acids; bentonites; gelatin;polyvinylpyrrolidone/vinyl acetate copolymer; crospovidonc; povidonc;starch; prcgclatinized starch; tragacanth, dextrin, a sugar, such assucrose (e.g., Dipac®), glucose, dextrose, molasses, mannitol, sorbitol,xylitol (e.g., Xylitab®), and lactose; a natural or synthetic gum suchas acacia, tragacanth, ghatti gum, mucilage of isapol husks,polyvinylpyrrolidone (e.g., Polyvidone® CL, Kollidon® CL, Polyplasdone®XL-10), larch arabogalactan, Veegum®, polyethylene glycol, waxes, sodiumalginate, and the like.

Disintegrants facilitate breakup or disintegration of oral solid dosageforms after administration. Examples of disintegrants include a starch,e.g., a natural starch such as corn starch or potato starch, apregelatinized starch such as National 1551 or Amijcl®, or sodium starchglycolate such as Promogel® or Explotab®; a cellulose such as a woodproduct, methylcrystalline cellulose, e.g., Avice10, Avicel® PH101,Avicel® PH102, Avicel® PH105, Elcema® P100, Emcocel®, Vivacel®, MingTia®, and Solka-Floc®, methylcellulose, croscarmellose, or across-linked cellulose, such as cross-linked sodiumcarboxymethylcellulose (Ac-Di-Solt), cross-linkedcarboxymethylcellulose, or cross-linked croscarmellose; a cross-linkedstarch such as sodium starch glycolate; a cross-linked polymer such ascrospovidone; a cross-linked polyvinylpyrrolidone; alginate such asalginic acid or a salt of alginic acid such as sodium alginate; a claysuch as Veegum® HV (magnesium aluminum silicate); a gum such as agar,guar, locust bean, Karaya, pectin, or tragacanth; sodium starchglycolate; bentonite; a natural sponge; a resin such as acation-exchange resin; citrus pulp; sodium lauryl sulfate; sodium laurylsulfate in combination starch; and the like.

Lubricants are compounds which prevent, reduce or inhibit adhesion orfriction of materials. Exemplary lubricants include, e.g., stearic acid;calcium hydroxide; talc; sodium stearyl fumerate; a hydrocarbon such asmineral oil, hydrogenated castor oil or hydrogenated vegetable oil suchas hydrogenated soybean oil (Sterotex®); higher fatty acids and theiralkali-metal and alkaline earth metal salts, such as aluminum, calcium,magnesium, zinc; stearic acid, sodium stearates, magnesium stearates,glycerol, talc, waxes, Stearowet® boric acid, sodium benzoate, sodiumacetate, sodium chloride, leucine, a polyethylene glycol or amethoxypolyethylene glycol such as Carbowax™, ethylene oxide polymers,sodium oleate, glyceryl behenate (E.g. Compritol 888 Ato), glyceryldisterate (Precirol Ato 5), polyethylene glycol, magnesium or sodiumlauryl sulfate, colloidal silica such as SyloidTM, Carb-O-Si10,DL-leucine, a starch such as corn starch, silicone oil, a surfactant,and the like.

Flow-aids or glidants improve the flow characteristics of powdermixtures. Such compounds include, e.g., colloidal silicon dioxide suchas Cab-o-sil®; tribasic calcium phosphate, talc, corn starch,DL-leucine, sodium lauryl sulfate, magnesium stearate, calcium stearate,sodium stearate, kaolin, and micronized amorphous silicon dioxide(Syloid®)and the like.

Plasticizers aid in coating of oral solid dosage forms. Exemplaryplasticizers include, but are not limited to, triethyl citrate,triacetin (glyceryl triacetate), acetyl triethyl citrate, polyethyleneglycols (PEG 4000, PEG 6000, PEG 8000), Carbowax 400 (polyethyleneglycol 400), diethyl phthalate, diethyl sebacate, acetyltriethylcitrate,oleic acid, glyceralmonosterate, tributyl citrate, acetylatedmonoglycerides, glycerol, fatty acid esters, propylene glycol, anddibutyl phthalate and the like.

The aforementioned excipients are given as examples only and are notmeant to include all possible choices. Other suitable excipient classesinclude coloring agents, granulating agents, preservatives, anti-foamingagents, solubulizers and the like. Additionally, many excipients canhave more than one role or function, or can be classified in more thanone group; the classifications arc descriptive only, and arc notintended to limit any use of a particular excipient.

Methods for Evaluating Treatment

Evaluation of Treatment of Diabetes

The effect of the biguanide compound treatment of the invention onaspects of diabetic disease can be evaluated according to methods knownin the art and common practiced by physicians treating diabeticpatients.

Efficacy of treatment of diabetes/metabolic syndrome anddiabetes-associated conditions with the compositions and methodsdescribed herein can be assessed using assays and methodologies known inthe art. By way of example, quantitative assessment of renal functionand parameters of renal dysfunction are well known in the art. Examplesof assays for the determination of renal function/dysfunction includescrum creatinine level; creatinine clearance rate; cystatin C clearancerate, 24-hour urinary creatinine clearance, 24-hour urinary proteinsecretion; Glomerular filtration rate (GFR); urinary albumin creatinineratio (ACR); albumin excretion rate (AER); and renal biopsy.

Quantitative assessment of pancreatic function and parameters ofpancreatic dysfunction or insufficiency are also well known in the art.Examples of assays for the determination of pancreasfunction/dysfunction include evaluating pancreatic functions usingbiological and/or physiological parameters such as assessment of isletsof Langerhans size, growth and/or secreting activity, beta-cells size,growth and/or secreting activity, insulin secretion and circulatingblood levels, glucose blood levels, imaging of the pancreas, andpancreas biopsy, glucose uptake studies by oral glucose challenge,assessment of cytokine profiles, blood-gas analysis, extent ofblood-perfusion of tissues, and angiogenesis within tissues.

Additional assays for treatment of diabetes and diabetes-associatedconditions are known in the art and are contemplated herein.

Evaluation of Treatment of Weight Loss, Obesity and Eating Disorders

In treatment of obesity it is desired that weight and/or fat is reducedin a patient. By reducing weight it is meant that the patient loses aportion of his/her total body weight over the course of treatment(whether the course of treatment be days, weeks, months or years).Alternatively, reducing weight can be defined as a decrease inproportion of fat mass to lean mass (in other words, the patient haslost fat mass, but maintained or gained lean mass, without necessarily acorresponding loss in total body weight). An effective amount of a thebiguanide compound treatment administered in this embodiment is anamount effective to reduce a patient's body weight over the course ofthe treatment, or alternatively an amount effective to reduce thepatient's percentage of fat mass over the course of the treatment. Incertain embodiments, the patient's body weight is reduced, over thecourse of treatment, by at least about 1%, by at least about 5%, by atleast about 10%, by at least about 15%, or by at least about 20%.Alternatively, the patient's percentage of fat mass is reduced, over thecourse of treatment, by at least 1%, at least 5%, at least 10%, at least15%, at least 20%, or at least 25%.

Total body weight and fat content can be measured at the end of thedietary period. In rats, a frequently used method to determine totalbody fat is to surgically remove and weigh the retroperitoneal fat pad,a body of fat located in the retroperitoneum, the area between theposterior abdominal wall and the posterior parietal peritoneum. The padweight is considered to be directly related to percent body fat of theanimal. Since the relationship between body weight and body fat in ratsis linear, obese animals have a correspondingly higher percent of bodyfat and retroperitoneal fat pad weight.

In embodiments wherein methods of treating, reducing, or preventing foodcravings in a patient are provided, food cravings can be measured byusing a questionnaire, whether known in the art or created by the personstudying the food cravings. Such a questionnaire would preferably rankthe level of food cravings on a numerical scale, with the patientmarking 0 if they have no food cravings, and marking (if on a scale of1-10) 10 if the patient has severe food cravings. The questionnairewould preferably also include questions as to what types of food thepatient is craving. Binge eating can be determined or measured using aquestionnaire and a Binge Eating Scale (BES). Binge eating severity canbe divided into three categories (mild, moderate, and severe) based onthe total BES score (calculated by summing the scores for eachindividual item). Accordingly, methods are provided for reducing the BESscore of a patient comprising administering to a patient in need thereofa compound treatment in an amount effective to reduce the BES score ofthe patient. In some embodiments, administration of a compound treatmentchanges the BES category of the patient, for example, from severe tomoderate, from severe to mild, or from moderate to mild.

Pre-Treatment Evaluation of Patient Hormonal Profile

In some embodiments, patients are pre-evaluated for expression ofmetabolic hormones using methods described herein. The therapy providedto the individual can thus be targeted to his or her specific needs. Inembodiments, a patient's hormonal profile is pre-evaluated and dependingon the changes that the physician desires to affect, a certaindetermined amount of the compound/metabolite combination isadministered. The evaluation process can be repeated and the treatmentadjusted accordingly at any time during or following treatment.

Hormone Assays

In embodiments, the levels of hormones assayed in association with themethods of the invention, including, but not limited to, GLP-1, GLP-2,GIP, oxyntomodulin, PYY, CCK, glycentin, insulin, glucagon, ghrelin,amylin, uroguanylin, C-peptide and/or combinations thereof are detectedaccording to standard methods described in the literature. For example,proteins can be measured by immunological assays, and transcriptionproducts by nucleic acid amplification techniques. Functional assaysdescribed in the art can also be used as appropriate. In embodiments,samples assayed comprise cultured cells, patient cell or tissue samples,patient body fluids, e.g., blood or plasma, etc. Similarly, the levelsof analytes (e.g., glucose, triglycerides, HDL, LDL, apoB and the like)assayed in association with the methods of the invention are detectedaccording to any known method.

For example, immunofluorescence can be used to assay for GLP-1. Cellscan be grown on matrigel-coated cover slips to confluent monolayers in12-well plates at 37° C., fixed in 4% paraformaldehyde inphosphate-buffered saline (PBS) and incubated with primary antiserum(e.g., rabbit anti-alpha gustducin, 1:150; Santa Cruz Biotechnology, andrabbit anti-GLP-1, Phoenix) overnight at 4° C. followingpermeabilization with 0.4% Triton-X in PBS for 10 minutes and blockingfor 1 hour at room temperature. Following three washing steps withblocking buffer, the appropriate secondary antibody is applied(AlexaFluor 488 anti-rabbit immunoglobulin, 1:1000; Molecular Probes)for 1 hour at room temperature. After three washing steps, the cells canbe fixed in Vectashield medium and the immunofluorescence visualized.

GLP-1 RNA isolated from cells can be assayed using RT-PCR. RT-PCR RNAisolation from cells can be performed using standard methodology. TheRT-PCR reaction can be performed in a volume of 50 pl in a Peltierthermal cycler (PTC-225 DNA Engine Tetrad Cycler; MJ Research), usingpublished primer sequences (Integrated DNA Technologies). Reversetranscription can be performed at 50° C. for 30 minutes; after aninitial activation step at 95° C. for 15 minutes. PCR can be performedby denaturing at 94° C. for 1 minute, annealing at 55° C. for 1 minuteand extension at 72° C. for 1 minute for 40 cycles, followed by a finalextension step at 72° C. for 10 minutes. Negative controls can beincluded as appropriate, for example, by substituting water for theomitted reverse transcriptase or template. The control can be RNAisolated from, e.g., rat lingual epithelium. PCR products can beseparated in 2% agarose gel with ethidium bromide, and visualized underUV light.

Radioimmunoassay (RIA) for total GLP-1 in patient blood samples can beperformed as described in the art, e.g., by Laferrere, et al., 2007,“Incretin Levels and Effect are Markedly Enhanced 1 Month afterRoux-en-Y Gastric Bypass Surgery in Obese Patients with Type 2 Diabetes,Diabetes Care 30(7):1709-1716 (using commercially available materialsobtained from Phoenix Pharmaceutical, Belmont, Calif.). The authorsdescribe measuring the effect of GIP and GLP-1 on secretion of insulinby measuring the difference in insulin secretion (area under the curve,or AUC) in response to an oral glucose tolerance test and to anisoglycemic intravenous glucose test.

Measurement of plasma concentrations of GLP-1, GIP, glucagon, insulin, Cpeptide, pancreatic peptide, nonesterified fatty acids, glutamic aciddecarboxylase antibodies, and islet antigen antibodies, is described,e.g., by Toft-Nielsen, et al., 2001, “Determinants of the ImpairedSecretion of Glucagon-Like Peptide-1 in Type 2 Diabetic Patients,” J.Clin. End. Met. 86(8):3717-3723. The authors describe the use ofradioimmunoassay for GLP-1 to measure plasma concentrations of amidatedGLP-1-(7-36), using antibody code no. 89390. This assay measures the sumof GLP-1-(7-36) and its metabolite GLP-1-(9-36). The authors describemeasurement of GIP using C-terminally directed antibody code no. R65(RIA), that reacts 100% with a human GIP but not with 8-kDA GIP.

GLP-1 and PYY can be directly assayed in the supernatant from venouseffluents as described by, e.g., Claustre, et al. (1999, “Stimulatoryeffect of (3-adrenergic agonists on ileal L cell secretion andmodulation by a-adrenergic activation, J. Endocrin. 162:271-8). (Seealso Plaisancie' et al., 1994, “Regulation of glucagon-likepeptide-1-(7-36) amide secretion by intestinal neurotransmitters andhormones in the isolated vascularly perfused rat colon,” Endocrinology135:2398-2403 and Plaisancie ‘ et al., 1995, “Release of peptide YY byneurotransmitters and gut hormones in the isolated, vascularly perfusedrat colon,” Scandinavian Journal of Gastroenterology 30:568-574.) Inthis method, the 199D anti-GLP-1 antibody is used at a 1:250 000dilution. This antibody reacts 100% with GLP-1-(7-36) amide, 84% withGLP-1-(1-36) amide, and less than 0.1% with GLP-1-(1-37), GLP-1-(7-37),GLP-2, and glucagon. PYY is assayed with the A4D anti-porcine PYYantiserum at a 1:800 000 dilution.

Methods for assaying GLP-1 and GIP are also described elsewhere in theart, e.g., by Jong, et al., PNAS, 2007.

PYY can also be assayed in blood using a radioimmunoassay as describedby, e.g., Weickert, et al., 2006, “Soy isoflavones increase preprandialpeptide YY (PYY), but have no effect on ghrelin and body weight inhealthy postmenopausal women” Journal of Negative Results inBioMedicine, 5:11. Blood is collected in ice-chilled EDTA tubes for theanalysis of glucose, ghrelin, and PYY. Following centrifugation at 1600g for 10 minutes at 4° C., aliquots were immediately frozen at −20° C.until assayed. All samples from individual patients were measured in thesame assay. The authors described measuring immunoreactive total ghrelinwas measured by a commercially available radioimmunoassay (PhoenixPharmaceuticals, Mountain View, Calif., USA). (See also Weickert, etal., 2006, “Cereal fiber improves whole-body insulin sensitivity inoverweight and obese women,” Diabetes Care 29:775-780). Immunoreactivetotal human PYY is measured by a commercially available radioimmunoassay(IINCO Research, Missouri, USA), using 125I-labeled bioactivc PYY astracer and a PYY antiserum to determine the level of active PYY by thedouble antibody/PEG technique. The PYY antibody is raised in guinea pigsand recognizes both the PYY 1-36 and PYY 3-36 (active) forms of humanPYY.

SGLT-1, the intestinal sodium-dependent glucose transporter 1, is aprotein involved in providing glucose to the body. It has been reportedto be expressed in response to sugar in the lumen of the gut, through apathway involving T1R3 (Margolskee, et al., 2007 “T1R3 and gustducin ingut sense sugars to regulate expression of Na+-glucose cotransporter 1,”Proc Natl Acad Sci USA 104, 15075-15080”). Expression of SGLT-1 can bedetected as described, e.g., by Margolskee, et al., for example, usingquantitative PCR and Western Blotting methods known in the art.Measurement of glucose transport has been described in the literature,e.g., by Dyer, et al., 1997, Gut 41:56-9 and Dyer, et al., 2003, Eur. J.Biochem 270:3377-88. Measurement of glucose transport in brush bordermembrane vesicles can be made, e.g., by initiating D-glucose uptake bythe addition of 100 pl of incubation medium containing 100 mM NaSCN (orKSCN), 100 mM mannitol, 20 mM Hepes/Tris (pH 7.4), 0.1 mM MgSO4, 0.02%(wt/vol) NaN3, and 0.1 mM D-[U14C]glucose to BBMV (100 μg of protein).The reaction is stopped after 3 sec by addition of 1 ml of ice-cold stopbuffer, containing 150 mM KSCN, 20 mM Hepes/Tris (pH 7.4), 0.1 mM MgSO4,0.02% (wt/vol) NaN3, and 0.1 mM phlorizin. A 0.9-ml portion of thereaction mixture is removed and filtered under vacuum through a 0.22-[tmpore cellulose acetate/nitrate filter (GSTF02500; Millipore, Bedford,MA). The filter is washed five times with 1 ml of stop buffer, and theradioactivity retained on the filter is measured by liquid scintillationcounting.

EXAMPLES Example 1 Enteroendocrine Production of PYY, GLP-1 (Active) andGLP-1 (Total) and Reduction of Glucose and Insulin is Independent ofPlasma Absorption of Metformin Example 1.1 Materials and Methods

Population: Approximately 18 eligible male and female subjects, 18 to 65years of age, with a BMI of 25.0 to 35.0 kg/m², were randomized in thisstudy. To be eligible, each subject also met the following criteria: (a)was not breastfeeding; (b) had a negative pregnancy test result (humanchorionic gonadotropin, beta subunit); (c) surgically sterile,postmenopausal, or if of childbearing potential, practiced appropriatebirth control during the entire duration of the study; (d) had aphysical examination with no clinically significant abnormalities,including but not limited to the following conditions: (i) Hepaticdisease; (ii) Renal disease; (iii) gastrointestinal disease; (iv)Endocrine disorder, including diabetes; (v) Cardiovascular disease; (vi)Seizure disorder; (vii) Organ transplantation; and (viii) Chronicinfection; and (e) an ability to understand and willingness to adhere toprotocol requirements.

Formulations

The metformin DR formulation was a US-supplied commercially availablefilm-coated immediate-release tablet containing 500 mg metforminhydrochloride, to which additional coatings (a seal coating and anenteric coating) were applied in order to delay release of the drug inthe GI tract until the tablet reached a pH 6.5 region of the distalsmall intestine. The tablets were white, biconvex, circular-shapedcoated tablets, each containing 500 mg metformin hydrochloride. Inactiveingredients in the commercially available tablet included povidone,magnesium stearate, hypromellose, and polyethylene glycol. Inactiveingredients in the additional coating systems included hypromellose,triacetin, talc, methacrylic acid copolymer (Eudragit® L30 D-55),poly(methyl acrylate-co-methyl methacrylate-co-methacrylic acid) 7:3:1(Eudragit® FS 30 D), sodium lauryl sulfate, polysorbate 80, glycerylmonostearate, and triethyl citrate.

The metformin IR formulation was the identical US-supplied commerciallyavailable film-coated immediate-release tablet containing 500 mgmetformin hydrochloride, to which only the additional seal coating isapplied. No delayed-release (enteric) coating was applied. Inactiveingredients in the additional seal coating system included hypromellose,triacetin and talc.

The metformin formulations were supplied to the site as bulk tabletspackaged in screw cap containers labeled with container number and lotnumber. All study medications were stored in cool and dry conditions asindicated on the label, and used only as directed by study personnel.Study medication was dispensed by the unblinded site pharmacist or studypersonnel according to the randomization scheme at the beginning of eachtreatment period.

Administration

Study medication was dispensed by an unblinded site pharmacist or studypersonnel according a randomization scheme at Visits 2 and 4. At the endof Visits 2 and 4, subjects were discharged from the clinic withassigned study medications and with instructions for self-administrationuntil they returned for their next study visit (Visit 3 or 5).

Study medication was administered orally as intact tablets (swallowedwhole, not chewed or crushed), and with water. The first dose and thelast two doses of study medication for each treatment period wereadministered to subjects by qualified study site personnel (first doseat Visits 2 and 4 and last two doses at Visits 3 and 5). Subjectsself-administered the assigned study medications according toinstructions until they returned for their next study visit (Visit 3 or5). Study site personnel contacted subjects by telephone on the secondday of dosing of each treatment period to assess compliance and adverseevents through non-directed questioning. If the subject was experiencingsignificant gastrointestinal symptoms, at the investigator's discretion,subjects were instructed not to dose escalate.

The procedures performed during the study are listed in Tables 1-3below.

TABLE 1 Study Plan (Protocol LCPOC6) Treatment Period 1 Treatment Period2 Day 2 of Day 2 of End of Baseline Treatment Baseline Treatment Period2/ of Period End of of Period Study Period 1 Phone Period 1 Period 2Phone Termination Early Evaluation Screen Visit 2 Call [1] Visit 3 Visit4 Call [1] Visit 5 Termination Fast (>8 Hours Overnight) X X X X XInformed Consent X Complete Medical History X Physical Examination andHeight X Body Weight and Vital Signs X X X X X X Chemistry, Hematology,Urinalysis X X X Pregnancy Test (Females) [2] X X X Randomization XTimed Blood Sampling [3] X X X X Study Medication Administration [4] X XX X Dispense Study Medication X X Study Medication Compliance X XAssessment and Collection Dose Escalation Phone Call X X ConcomitantMedications Assessment X X X X X X [1] Phone calls to assess complianceand adverse events through non-directed questioning and to remindsubjects to dose escalate [2] Pregnancy test required on all femalesubjects unless subject has had a hysterectomy or is postmenopausal. [3]GLP-1, PYY, plasma glucose, insulin, and triglycerides at Visits 2 and4; GLP-1, PYY, plasma glucose, insulin, triglycerides and metformin atVisits 3 and 5. After meal challenge at Visit 2 and Visit 4. Eveningdose on Day 4 and morning dose on Day 5 at Visit 3 and Visit 5.

TABLE 2 Schedule of Standardized Breakfast and Blood Sampling Profile atVisit 2 and Visit 4 Standardized Collect 6-mL Breakfast Time bloodsamples Administration (minutes) [1] [2] −15 X −5 X 0 X 30 X 45 X 60 X90 X 120 X 150 X 180 X 210 X 240 X 270 X 300 X 330 X [1] 6-mL bloodvolume total per sampling time point for assessment of PYY, GLP-1,plasma glucose, insulin, and triglycerides. [2] Subjects are to beinstructed to consume the standardized breakfast within 20 minutes.

TABLE 3 Day 5 Schedule of Dosing, Standardized Breakfast and BloodSampling Profile at Visit 3 and Visit 5 Standardized Collect 6-mLBreakfast Dose Collect 2-mL Time blood samples Administration Studyblood sample (minutes) [1] [2] Medication [3] −245 X −240 X −120 X −15 X−5 X X 0 X 30 X X 45 X X 60 X X 90 X X 120 X X 150 X X 180 X X 210 X X240 X X 270 X X 300 X X 330 X X 360 X 420 X 480 X [1] 6-mL blood volumetotal per sampling time point for assessment of PYY, GLP-1, plasmaglucose, insulin, and triglycerides. [2] Subjects are to be instructedto consume the standardized breakfast within 20 minutes. [3] 2-mL bloodvolume total per sampling time point for assessment of metformin.

Pharmacodynamic Assessments

Blood samples were collected according to the schedules presented inTables 1, 2, and 3, and as described above. Fasting and postprandialplasma concentrations of gut hormones GLP-1 and PYY, as well asconcentrations of plasma glucose, insulin, and triglycerides weremeasured by analytical methods. Blood samples from each visit wasprocessed and stored at −70° C. for future exploratory analysis ofadditional hormones.

Pharmacokinetic Assessments

Blood samples were collected according to the schedules presented inTables 1, 2, and 3, and as described above. Plasma metforminconcentrations were measured by analytical methods. Blood samples fromeach visit were processed and stored at −70° C. for future exploratoryanalysis of additional hormones.

Clinical Laboratory Evaluations

Samples were collected according to the schedules presented in Tables 1,2 and 3, and in the preceding section.

Chemistry

Chemistry assessments included the following: urea nitrogen, creatinine,total protein, albumin, uric acid, total bilirubin, alkalinephosphatasc, alaninc aminotransferasc, aspartate aminotransferase, gammaglutamyltranspeptidase, creatine phosphokinase, glucose, sodium,potassium, chloride, bicarbonate, phosphorus, lactate, and calcium (orother approved routine chemistry panels.

Hematology

Hematology assessments included the following: red cell count,hemoglobin, hematocrit, white cell count, platelets, differential count,mean cell volume, mean corpuscular hemoglobin, and mean corpuscularhemoglobin concentration (or other approved routine hematologyassessments).

Urinalysis

Urinalysis assessments included the following: pH, specific gravity,glucose, blood, ketones, and protein (or other approved routineurinalysis).

Pregnancy Testing

All female subjects, regardless of childbearing status (unless subjectwas post-menopausal or had a hysterectomy), provided blood or urine forpregnancy tests. Study medication was not administered unless a negativeresult was obtained.

Vital Signs and Other Observations Related to Safety

Clinically significant abnormalities in vital signs and otherobservations related to safety were followed up by the investigator andevaluated with additional tests if necessary, until the underlying causewas diagnosed or resolution occurred.

Vital Signs

Vital sign measurements included sitting systolic and diastolic bloodpressure, heart rate, and body temperature. Vital signs were measuredafter the subject rested for approximately 5 minutes and with thesubject in a sitting position. The blood pressure measurement wasrepeated after at least 30 seconds and the average of the two readingsrecorded.

Example 1.2 Results

The study design and event timeline are shown in FIGS. 1-2. Shown inTables 4 and 5 below arc the resulting subject disposition andpopulation (Table 4) and the demographic and baseline characteristics of18 subjects (Table 5).

TABLE 4 Subject Disposition and Population Parameter Result Randomized18 Completed 17 Withdrawal (positive drug test) 1 Evaluable Population16

-   -   2 subjects excluded from evaluable population; I withdrawn and I        could not complete test meal at end of Treatment Period 2

TABLE 5 Demographic and Baseline Characteristics (n = 18) ParameterResult Gender (M/F) 9/9 Mean Age (yr) ± SD 44 ± 10 Race 9 Caucasian, 7Hispanic, 2 black Mean BMI (kg/m2) ± SD 29.3 ± 2.8 

FIG. 3 demonstrates that ingestion of Metformin DR minimized adsorptionof metformin in the plasma compared to Metformin IR. The area under thecurve (AUC) and Cmax values for Metformin DR and Metformin IR areprovided in Table 6 below.

TABLE 6 Metformin Plasma Pharmacokinetics LS Mean Ratio ReMet/MetforminP Value Abs AUC 0.83 0.02 Abs Cmax 0.73 0.003 Incremental Cmax 0.45<0.001

FIG. 4A-C shows an increase in meal-enhanced gut hormones in 16 subjectsafter treatment of Metformin DR comparable to that of Metformin IR,although treatment with Metformin DR minimized the systemic level ofmetformin compared to Metformin IR (FIG. 3). Additionally, FIGS. 5A-Bshow a reduction in meal-enhanced glucose and insulin after treatmentwith Metformin DR in 16 subjects comparable to that of Metformin IR.FIG. 6 shows that treatment with Metformin DR results in a similar PYYresponse as Metformin IR, but has a lower systemic exposure. FIGS. 7A-Bshow that the metformin PK/PD relationship was dissociable in at leastone patient.

Example 2 A Randomized, Crossover Study to Assess Steady-State PK and PDof Delayed-Release and Immediate Release Metformin in Subjects with Type2 Diabetes Mellitus

This randomized, crossover study assessed the steady-statepharmacokinetics and pharmacodynamics (glucose, insulin, glucagon-likepeptide-1 [GLP-1], and peptide YY [PYY], of 500 mg and 1000 mg metformindelayed-release (Metformin DR), 1000 mg metformin immediate-release(Metformin IR), and 500 mg Metformin IR+1000 mg Metformin DR in subjectswith type 2 diabetes mellitus. Subjects managing their diabetes withoral anti-diabetic therapy must have been off of those medications forat least the fourteen days immediately prior to randomization.

Each treatment period was five days long and separated by washoutintervals of seven days. Each treatment period contained a standardizedbreakfast and lunch profile on Day 1 prior to administration of studydrug (baseline assessment) and an identical profile on the morning ofDay 5 (on-drug assessment).

Example 2.1 Materials and Methods

Subjects were evaluated for the effects of each treatment on circulatingPYY, GLP-1, glucose, and insulin concentrations over approximately 10hours in response to two standardized meals (˜500 kcal standardizedbreakfast at t=0 min, and ˜1000 kcal standardized lunch at t=300 min)using standard protocols. Metformin pharmacokinetics over anapproximately 11-hour sampling period were also evaluated.

Population: Most randomized subjects were White (79.2%), and half werefemale (50.0%). The mean age was 51.3 years, the mean weight was 93.4kg, and the mean BMI was 33.3 kg/m² at baseline. Nineteen of the 24subjects completed the study.

The primary population for pharmacokinetic and pharmacodynamic analyseswas the Evaluable Population (N=19), defined as all subjects whocompleted all treatment periods consistent with protocol procedures. Theprimary population for safety analyses was the Intent-to-Treat (ITT)Population (N=24), defined as all subjects who received at least onedose of study medication.

Formulations

The metformin DR formulation was a US-supplied commercially availablefilm-coated immediate-release tablet containing 500 mg metforminhydrochloride, to which additional coatings (a seal coating and anenteric coating) were applied in order to delay release of the drug inthe GI tract until the tablet reaches a pH 6.5 region of the the distalsmall intestine. The tablets are white, biconvex, circular-shaped coatedtablets, each containing 500 mg metformin hydrochloride. Inactiveingredients in the commercially available tablet included povidone,magnesium stearate, hypromellose, and polyethylene glycol. Inactiveingredients in the additional Elcelyx coating systems includedhypromellose, triacetin, talc, methacrylic acid copolymer (Eudragit® L30D-55), poly(methyl acrylate-co-methyl methacrylate-co-methacrylic acid)7:3:1 (Eudragit® FS 30 D), sodium lauryl sulfate, polysorbate 80,glyceryl monostearate, and triethyl citrate.

The metformin IR formulation was the identical US-supplied commerciallyavailable film-coated immediate-release tablet containing 500 mgmetformin hydrochloride, to which only the additional seal coating isapplied. No delayed-release (enteric) coating was applied. Inactiveingredients in the additional seal coating system included hypromellose,triacetin and talc.

The metformin formulations were supplied to the site as bulk tabletspackaged in screw cap containers labeled with container number and lotnumber. All study medications were stored in cool and dry conditions asindicated on the label, and used only as directed by study personnel.Study medication was dispensed by the unblinded site pharmacist or studypersonnel according to the randomization scheme at the beginning of eachtreatment period.

Administration

Study medication was administered orally as intact tablets (swallowedwhole) with water at the beginning of the breakfast and dinner meals.Subjects self-administered their assigned study medications on theevening of Day 1 through the morning of Day 4 according to instructionsprovided on Day 1 by the study site staff. The last two doses of studymedication for each treatment period (evening of Day 4 and morning ofDay 5) were administered to subjects by qualified study site personnel.In order to reduce gastrointestinal side effects, all treatment regimensinitiated treatment at 500 mg/dose for the first 3 doses, followed by anincrease to the randomized dose (500 mg/dose, 1000 mg, or 1500 mg/dose)for the remainder of the study period. Study site personnel contactedsubjects by telephone on the second day of dosing of each treatmentperiod to assess compliance and adverse events through non-directedquestioning and to remind them to dose-escalate if appropriate.

Example 2.2 Results Pharmacokinetic Evaluations

Pharmacokinetic Profiles

FIG. 8 presents the mean plasma metformin concentrations at Day 5 bytreatment and time point. On Day 5, the pre-dose mean concentration ofMetformin IR at t=0 was 350 ng/mL, which is consistent with steady-statetrough concentrations published in the literature. After theadministration of Metformin IR at t=−1 minute, there was a rapidincrease in metformin concentrations that peaked at 1249 ng/mL 90 minafter the dose followed by a steady decline for the remainder of thesampling period.

The pre-dose concentrations for both doses of Metformin DR wereapproximately 2 times higher than those for Metformin IR (716 ng/mL for1000 mg DR and 602 ng/mL for 500 ng/mL DR vs. 350 ng/dL for 1000 mg IR).Following the administration of both doses of metformin DR at t=−1minute, there was a decrease in metformin concentrations for the first240 minutes followed by a small rise in metformin concentrations afterthe standardized lunch meal, which then plateaued for the remainder ofthe sampling period. The entire 11-hour metformin profiles remainedbelow the pre-dose concentrations measured at t=0. The absorptionprofiles for Metformin DR dosing with the evening meal were slowedrelative to doses administered with the breakfast meal, consistent withslowed intestinal transit during the sleeping hours. Metformin DRconcentrations for the 500-mg dose were lower than the 1000-mg dose atall time points although the reductions were less thandose-proportional. This observation is consistent with the lack ofdose-proportionality reported for Metformin IR and could be due to asaturable absorption process in the gut.

The Metfo tin DR+Metformin IR treatment group had the highest pre-doseconcentrations of the four treatment groups (761 ng/mL). Following theadministration of study medication at t=−1 minute, metforminconcentrations rapidly rose in a manner similar to metformin IR butgenerally remained below the Metformin IR concentration curve for thefirst 500 minutes. For the remainder of the sampling period,concentrations plateaued but where higher than those observed with theother treatments.

Pharmacokinetic Parameters

Table 7 and FIG. 9 present the relative bioavailability of metformin bytreatment versus Metformin IR at Day 5. Compared to the Metformin IRformulation the metformin exposure from t=0 to time of lastconcentration after study medication administration (AUC_(0-t)) wasstatistically significantly reduced by 45.2% with 1000 mg Metformin DR(% mean ratio of 54.8; p<0.0001) and 56.6% with 500 mg Metformin DR (%mean ratio of 43.4; p<0.0001). Compared to Metformin IR, C_(max) wasalso was statistically significantly reduced by 34.9% with 1000 mgMetformin DR (% mean ratio of 65.1; p<0.0001) and 47.7% with 500 mgmetformin DR (% mean ratio of 52.3; p<0.0001).

The Metformin DR+IR treatment resulted in exposures similar to that ofthe 1000 mg Metformin IR (% mean ratio of 90.9; p=0.2271) despite anincrease in daily dose of 50%.

TABLE 7 Relative Bioavailability of Metformin by Treatment versusMetformin IR at Day 5 - Evaluable Population 500 mg Met IR + 1000 mg MetIR 1000 mg Met DR 500 mg Met DR 1000 mg Met DR Statistic (N = 19) (N =19) (N = 19) (N = 19) AUC_(0-t) (ng*h/mL) Geometric LS mean 8325 45593614 7567 % ratio [1] Geometric LS mean NA 54.8 43.4 90.9 90% CI NA48.1, 62.4 38.1, 49.5 79.8, 103.6 p value NA <0.0001 <0.0001 0.2271Cmax_(0-t) (ng/mL) Geometric LS mean 1283 836 671 1150 % ratio [1]Geometric LS mean NA 65.1 52.3 89.6 90% CI of % ratio NA 56.5, 75.045.4, 60.3 77.8, 103.3 p value of % ratio NA <0.0001 <0.0001 0.2016Abbreviations: NA = not applicable; t = last quantifiable concentrationfollowing dose administration. Note: Intra subject CV % was 24.2 forAUC_(0-t) and 26.3 for C_(max). [1] (1000 mg Met IR, 1000 mg Met DR, or500 mg Met DR)/1000 mg Met IR.

Pharmacodynamic Evaluations

PYY Total

FIG. 10 and Table 8 present the mean plasma PYY total concentrationprofiles at baseline and Day 5 by treatment and time point and thecorresponding analysis of pharmacodynamic parameters, respectively.Baseline plasma PYY total concentrations were similar between treatmentsat most time points. Additionally, all metformin treatmentsstatistically significantly increased PYY total exposure and peakconcentrations (p<0.01 for all), with percent ratios (Day5/Day1) forAUC_(0 t) and Cmax ranging from 1.26 to 1.55. Fasting plasma PYY totalconcentrations were also statistically significantly increased frombaseline at Day 5 for each treatment (Table 9, p<0.01 for all). Theseresults indicate that all of the treatments studied elicited similar PYYtotal responses to two standardized meals.

TABLE 8 Pharmacodynamic Analysis of Plasma PYY Total (pg/mL) - Within-Treatment Comparison Based on Ratios - Evaluable Population 500 mg MetIR + 1000 mg Met IR 1000 mg Met DR 500 mg Met DR 1000 mg Met DRStatistic (N = 19) (N = 19) (N = 19) (N = 19) AUC_(0-t) (pg/mL*min) BLgeo. LS mean (SE) 51487 (5104) 51518 (5579) 50932 (5587) 51985 (5614)EOT geo. LS mean (SE) 79654 (7897) 71218 (7712) 74546 (8178) 77270(8344) % ratio [1] Geo. LS mean (SE)  1.55 (0.09)  1.38 (0.09)  1.46(0.06)  1.49 (0.06) 95% CI 1.36, 1.75 1.22, 1.57 1.34, 1.59 1.36, 1.62 pvalue <0.0001 <0.0001 <0.0001 <0.0001 Cmax_(0-t) (pg/mL) BL geo. LS mean(SE) 124 (13) 135 (16) 122 (13) 129 (15) EOT geo. LS mean (SE) 190 (19)169 (20) 169 (18) 184 (21) % ratio [1] Geo. LS mean (SE)  1.53 (0.10) 1.26 (0.09)  1.38 (0.08)  1.43 (0.06) 95% CI 1.34, 1.75 1.08, 1.471.23, 1.55 1.31, 1.56 p value <0.0001  0.0056 <0.0001 <0.0001Abbreviations: BL = baseline (Day 1); EOT = end of treatment (Day 5);geo. = geometric; t = last quantifiable concentration following doseadministration. [1] EOT (Day 5)/BL (Day 1) for each treatment

TABLE 9 Fasting Plasma PYY Total (pg/mL) at Baseline and Day 5 -Evaluable Population 500 mg Met IR + 1000 mg Met IR 1000 mg Met DR 500mg Met DR 1000 mg Met DR Statistic (N = 19) (N = 19) (N = 19) (N = 19)BL LS mean (SE) 59.47 (10.22) 56.26 (8.32) 53.39 (11.42) 59.11 (12.90)EOT LS mean (SE) 94.75 (10.22) 75.80 (8.32) 91.13 (11.42) 92.92 (12.90)LS mean diff (SE) 35.28 (6.64)  19.53 (6.17) 37.73 (10.41) 33.81 (9.91) 95% CI 21.28, 49.28 6.51, 32.56 15.77, 59.69 12.90, 54.71 p value <.00010.0057 0.0021 0.0033 Abbreviations: BL = baseline (Day 1); EOT = end oftreatment (Day 5).

GLP-1 Active

FIG. 11 and Table 10 present the mean plasma GLP-1 active concentrationprofiles at baseline and Day 5 by treatment and time point and thecorresponding analysis of pharmacodynamic parameters, respectively.Baseline plasma GLP-1 active concentrations were similar betweentreatments at most time points. Additionally, all metformin treatmentsstatistically significantly increased GLP-1 active exposure and peakconcentrations (p<0.01 for all), with percent ratios (Day5/Day1) forAUC0-t and Cmax ranging from 1.42 to 1.88. Fasting plasma GLP-1 totalconcentrations were also statistically significantly increased frombaseline at Day 5 for each treatment (Table 11, p<0.05 for all). Theseresults indicate that all of the treatments studied elicited similarGLP-1 active responses to two standardized meals.

TABLE 10 Pharmacodynamic Analysis of Plasma GLP-1 Active (pmol/L) -Within- Treatment Comparison Based on Ratios - Evaluable Population 500mg Met IR + 1000 mg Met IR 1000 mg Met DR 500 mg Met DR 1000 mg Met DRStatistic (N = 19) (N = 19) (N = 19) (N = 19) AUC_(0-t) (pmol/L*min) BLgeo. LS mean (SE) 3031 (386) 3059 (405) 3547 (447) 3277 (380) EOT geo.LS mean (SE) 5655 (719) 4953 (655) 5993 (755) 6158 (714) % ratio [1]Geo. LS mean (SE)  1.87 (0.18)  1.62 (0.11)  1.69 (0.15)  1.88 (0.19)95% CI 1.52, 2.29 1.40, 1.87 1.41, 2.03 1.52, 2.33 p value <0.0001<0.0001 <0.0001 <0.0001 Cmax_(0-t) (pmol/L) BL geo. LS mean (SE) 11.3(1.4) 10.6 (1.3) 13.9 (1.5) 12.0 (1.3) EOT geo. LS mean (SE) 19.2 (2.3)17.3 (2.1) 19.7 (2.1) 21.1 (2.3) % ratio [1] Geo. LS mean (SE)  1.70(0.16)  1.64 (0.17)  1.42 (0.14)  1.76 (0.19) 95% CI 1.40, 2.07 1.32,2.03 1.15, 1.76 1.40, 2.21 p value <0.0001  0.0001 0.0025 <0.0001Abbreviations: BL = baseline (Day 1); EOT = end of treatment (Day 5);geo. = geometric; t = last quantifiable concentration following doseadministration. [1] EOT (Day 5)/BL (Day 1) for each treatment.

TABLE 11 Fasting Plasma GLP-1 Active (pmol/L) at Baseline and Day 5 -Evaluable Population 500 mg Met IR + 1000 mg Met IR 1000 mg Met DR 500mg Met DR 1000 mg Met DR Statistic (N = 19) (N = 19) (N = 19) (N = 19)BL LS mean (SE) 3.79 (1.16) 3.93 (1.19) 4.73 (1.31) 3.69 (1.04) EOT LSmean (SE) 6.32 (1.16) 5.10 (1.19) 6.62 (1.31) 5.64 (1.04) LS mean diff(SE) 2.53 (0.83) 1.17 (0.54) 1.89 (0.45) 1.95 (0.91) 95% CI 0.80, 4.260.03, 2.31 0.96, 2.83 0.03, 3.87 p value 0.0067 0.0444 0.0005 0.0466Abbreviations: BL = baseline (Day 1); EOT = end of treatment (Day 5).

Glucose

FIG. 12 and Table 12 present mean plasma glucose concentration profilesat baseline and Day 5 by treatment and timepoint and the correspondingpharmacodynamic parameters by meal, respectively.

Baseline plasma glucose concentrations were similar between treatmentsat most time points. Additionally, all metformin treatmentsstatistically significantly decreased glucose exposure and peakconcentrations for both meal intervals to a similar extent (p<0.001 forall).

TABLE 12 Pharmacodynamic Analysis of Plasma Glucose (mg/dL) by MealInterval - Within-Treatment Comparison Based on Ratios - EvaluablePopulation 500 mg Met IR + 1000 mg Met IR 1000 mg Met DR 500 mg Met DR1000 mg Met DR Statistic (N = 19) (N = 19) (N = 19) (N = 19) BreakfastInterval AUC_(0-t295) (mg/dL*min) BL geo. LS mean (SE) 66642 (5480)66257 (5815) 65755 (5906) 66507 (5617) EOT geo. LS mean (SE) 57007(4688) 59269 (5201) 60346 (5420) 56658 (4785) % ratio [1] Geo. LS mean(SE)  0.86 (0.02)  0.90 (0.02)  0.92 (0.01)  0.85 (0.02) 95% CI 0.81,0.91 0.86, 0.93 0.89, 0.95 0.81, 0.90 p value <0.0001 <0.0001 <0.0001<0.0001 Cmax_(0-t295) (mg/dL) BL geo. LS mean (SE) 291 (21) 290 (22) 292(24) 290 (20) EOT geo. LS mean (SE) 255 (19) 261 (20) 263 (21) 248 (17)% ratio [1] Geo. LS mean (SE)  0.88 (0.02)  0.90 (0.02)  0.90 (0.01) 0.85 (0.02) 95% CI 0.83, 0.92 0.86, 0.95 0.88, 0.93 0.81, 0.90 p value<0.0001  0.0004 <0.0001 <0.0001 Lunch Interval AUC_(t295-t) (pg/mL*min)BL geo. LS mean (SE) 76286 (6051) 75132 (6199) 74566 (6634) 74799 (5972)EOT geo. LS mean (SE) 65558 (5200) 66330 (5473) 68480 (6093) 63495(5070) % ratio [1] Geo. LS mean (SE)  0.86 (0.02)  0.88 (0.02)  0.92(0.02)  0.85 (0.03) 95% CI 0.82, 0.91 0.85, 0.92 0.88, 0.95 0.79, 0.91 pvalue <0.0001 <0.0001  0.0002  0.0001 Cmax_(t295-t) (pg/mL) BL geo. LSmean (SE) 295 (22) 288 (21) 287 (23) 293 (22) EOT geo. LS mean (SE) 250(19) 255 (19) 265 (22) 245 (19) % ratio [1] Geo. LS mean (SE)  0.85(0.03)  0.89 (0.02)  0.93 (0.02)  0.84 (0.03) 95% CI 0.80, 0.90 0.85,0.92 0.89, 0.96 0.78, 0.90 p value <0.0001 <0.0001  0.0002 <0.0001Abbreviations: BL = baseline (Day 1); EOT = end of treatment (Day 5); t= last quantifiable concentration following dose administration. [1] EOT(Day 5)/BL (Day 1) for each treatment.

Table 13 presents the pharmacodynamic parameters for glucose from t=0 totime of last concentration after study medication administration.Consistent with the pharmacodynamic parameters for the breakfast andlunch intervals, all metformin treatments statistically significantlydecreased glucose exposure and peak concentrations (p<0.001 for all),with percent ratios (Day5/Dayl) for AUC_(0-t) and Cmax ranging from 0.84to 0.92.

TABLE 13 Pharmacodynamic Analysis of Plasma Glucose (mg/dL) and Insulin(pmol/L) - Within-Treatment Comparison Based on Ratios - EvaluablePopulation 500 mg Met IR + 1000 mg Met IR 1000 mg Met DR 500 mg Met DR1000 mg Met DR Statistic (N = 19) (N = 19) (N = 19) (N = 19) GlucoseAUC_(0-t) (mg/dL*min) BL geo. LS mean (SE) 143041 (11408) 141572 (11884)140503 (12403) 141502 (11477) EOT geo. LS mean (SE) 122748 (9789) 125742 (10556) 129029 (11390) 120255 (9754)  % ratio [1] Geo. LS mean(SE)  0.86 (0.02)  0.89 (0.01)  0.92 (0.01)  0.85 (0.02) 95% CI 0.82,0.90 0.86, 0.92 0.89, 0.95 0.80, 0.90 p value <0.0001  <0.0001 <0.0001<0.0001 Cmax_(0-t) (mg/dL) BL geo. LS mean (SE) 301 (22) 301 (22) 301(24) 304 (22) EOT geo. LS mean (SE) 265 (19) 269 (19) 277 (22) 256 (19)% ratio [1] Geo. LS mean (SE)  0.88 (0.03)  0.89 (0.02)  0.92 (0.01) 0.84 (0.02) 95% CI 0.83, 0.93 0.86, 0.93 0.90, 0.95 0.79, 0.90 p value0.0002 <0.0001 <0.0001 <0.0001 Insulin AUC_(0-t) (pmol/L*min) BL geo. LSmean (SE) 191826 (26987) 176384 (30776) 199339 (28758) 191204 (26683)EOT geo. LS mean (SE) 186379 (26145) 175190 (30567) 194650 (28049)184975 (25814) % ratio [1] Geo. LS mean (SE)  0.97 (0.05)  0.99 (0.04) 0.98 (0.03)  0.97 (0.04) 95% CI 0.88, 1.08 0.92, 1.08 0.91, 1.04 0.89,1.05 p value 0.5587  0.8622  0.4551  0.4070 Cmax_(0-t) (pmol/L) BL geo.LS mean (SE) 594 (88)  664 (112) 604 (96) 598 (92) EOT geo. LS mean (SE)539 (80) 586 (99) 578 (92) 539 (83) % ratio [1] Geo. LS mean (SE)  0.91(0.06)  0.88 (0.09)  0.96 (0.06)  0.90 (0.06) 95% CI 0.79, 1.04 0.72,1.08 0.85, 1.08 0.79, 1.03 p value 0.1462  0.2167  0.4649  0.1110Abbreviations: BL = baseline (Day 1); EOT = end of treatment (Day 5); t= last quantifiable concentration following dose administration. [1] EOT(Day 5)/BL (Day 1) for each treatment.

Table 14 presents the LS mean (SE) and FIG. 13 presents the individualchange in fasting plasma glucose concentrations from baseline to Day 5by treatment. Baseline fasting glucose concentrations were similar andranged from 196 mg/dL to 200 mg/dL among the treatment groups. Alltreatment groups achieved statistically significant reductions (p<0.01for all) in fasting plasma glucose after 5 days of treatment. As shownin FIG. 13, the LSM and distribution of individual responses weresimilar between treatment groups.

TABLE 14 Fasting Plasma Glucose (mg/dL) at Baseline and Day 5 -Evaluable Population 500 mg Met IR + 1000 mg Met IR 1000 mg Met DR 500mg Met DR 1000 mg Met DR Statistic (N = 19) (N = 19) (N = 19) (N = 19)BL LS mean (SE) 200.3 (16.2) 197.0 (16.7) 198.7 (17.4) 195.9 (15.4) EOTLS mean (SE) 177.8 (16.2) 177.1 (16.7) 182.2 (17.4) 174.7 (15.4) LS meandiff (SE) −22.5 (6.8)  −19.9 (5.0)  −16.4 (3.8)  −21.2 (4.7)  95% CI−36.8, −8.16 −30.5, −9.3 −24.5, −8.4 −31.1, −11.2 p value 0.0040 0.00090.0004 0.0003 Abbreviations: BL = baseline (Day 1); EOT = end oftreatment (Day 5).

Insulin

Tables 15 and 16 present the pharmacodynamic parameters for insulin andbaseline and Day 5 fasting plasma insulin concentrations, respectively.There were no statistically significant changes in insulin exposure,peak concentrations, or fasting concentrations for any of the treatments(p>0.05 for all). Maintenance of insulin concentrations despite thelower circulating glucose concentrations is indicative of an incretineffect.

TABLE 15 Pharmacodynamic Analysis of Insulin (pmol/L) - Within-TreatmentComparison Based on Ratios - Evaluable Population 500 mg Met IR + 1000mg Met IR 1000 mg Met DR 500 mg Met DR 1000 mg Met DR Statistic (N = 19)(N = 19) (N = 19) (N = 19) AUC_(0-t) (pmol/L*min) BL geo. LS mean (SE)191826 (26987) 176384 (30776) 199339 (28758) 191204 (26683) EOT geo. LSmean (SE) 186379 (26145) 175190 (30567) 194650 (28049) 184975 (25814) %ratio [1] Geo. LS mean (SE)  0.97 (0.05)  0.99 (0.04)  0.98 (0.03)  0.97(0.04) 95% CI 0.88, 1.08 0.92, 1.08 0.91, 1.04 0.89, 1.05 p value 0.55870.8622 0.4551 0.4070 Cmax_(0-t) (pmol/L) BL geo. LS mean (SE) 594 (88) 664 (112) 604 (96) 598 (92) EOT geo. LS mean (SE) 539 (80) 586 (99) 578(92) 539 (83) % ratio [1] Geo. LS mean (SE)  0.91 (0.06)  0.88 (0.09) 0.96 (0.06)  0.90 (0.06) 95% CI 0.79, 1.04 0.72, 1.08 0.85, 1.08 0.79,1.03 p value 0.1462 0.2167 0.4649 0.1110 Abbreviations: BL = baseline(Day 1); EOT = end of treatment (Day 5); t = last quantifiableconcentration following dose administration. [1] EOT (Day 5)/BL (Day 1)for each treatment.

TABLE 16 Fasting Insulin (pmol/L) at Baseline and Day 5 - EvaluablePopulation 500 mg Met IR + 1000 mg Met IR 1000 mg Met DR 500 mg Met DR1000 mg Met DR Statistic (N = 19) (N = 19) (N = 19) (N = 19) BL LS mean(SE) 183.8 (42.3) 187.7 (29.0) 166.7 (34.5) 169.8 (29.9) EOT LS mean(SE) 151.9 (42.3) 138.1 (29.0) 157.8 (34.5) 147.0 (29.9) LS mean diff(SE) −31.8 (30.8) −49.6 (18.1)  −8.8 (13.2) −22.8 (8.6)  95% CI −96.5,32.8 −87.7, −11.6 −36.6, 18.9 −40.8, −4.8 p value 0.3146 0.0135 0.51090.0160 Abbreviations: BL = baseline (Day 1); EOT = end of treatment (Day5).

Safety Evaluations

Table 17 summarizes treatment-emergent adverse events by SOC, preferredterm, and most recent treatment at onset.

Consistent with the metformin prescribing information, adverse eventswere primarily gastrointestinal in nature with nausea, vomiting, andretching occurring only in the treatment groups receiving Metformin IRwith or without Metformin DR. Diarrhea was reported across all treatmentgroups and appeared to be dose-dependent with the greatest incidencewith Metformin IR+Metformin DR (7 subjects, 33.3%) and the lowestincidence with the lowest dose of Metformin DR (2 subjects, 10.0%). Ofnote, all gastrointestinal events in the 500 mg Metformin DR groupoccurred during the post-treatment washout period while off study drug.

Nervous system disorders such as dizziness and headache were also morefrequent with Metformin IR than either DR dosage. Overall, fewergastrointestinal and nervous system disorder adverse events werereported with the Metformin DR than metformin IR, indicating that thereduced systemic exposure to metformin achieved by bypassing theproximal small intestine improved tolerability.

TABLE 17 Summary of Treatment-Emergent Adverse Events by SOC andPreferred Term and Treatment at Onset - ITT Population 500 mg Met IR +1000 mg Met IR 1000 mg Met DR 500 mg Met DR 1000 mg Met DR SOC (N = 22)(N = 20) (N = 20) (N = 21) Preferred Term n (%) n (%) n (%) n (%) AnyTEAE   6 (27.3)   5 (25.0)   4 (20.0) 10 (47.6) Gastrointestinal   5(22.7)   3 (15.0)   2 (10.0)  8 (38.1) Disorders Abdominal Discomfort 0(0) 0 (0) 0 (0) 1 (4.8) Abdominal Distension 0 (0) 0 (0) 0 (0) 1 (4.8)Abdominal Pain 0 (0) 0 (0)  1 (5.0) 1 (4.8) Diarrhea   3 (13.6)   3(15.0)   2 (10.0)  7 (33.3) Dyspepsia  1 (4.5) 0 (0)  1 (5.0) 1 (4.8)Frequent Bowel 0 (0) 0 (0) 0 (0) 1 (4.8) Movements Nausea  2 (9.1) 0 (0)0 (0)  3 (14.3) Retching  1 (4.5) 0 (0) 0 (0) 0 (0)  Vomiting  2 (9.1) 0(0) 0 (0) 0 (0)  General Disorders And 0 (0) 0 (0)  1 (5.0) 0 (0) Administration Site Conditions Fatigue 0 (0) 0 (0)  1 (5.0) 0 (0) Infections And 0 (0) 0 (0) 0 (0) 1 (4.8) Infestations Oral Herpes 0 (0)0 (0) 0 (0) 1 (4.8) Investigations 0 (0) 0 (0) 0 (0) 1 (4.8) WeightDecreased 0 (0) 0 (0) 0 (0) 1 (4.8) Musculoskeletal And 0 (0)  1 (5.0) 0(0) 0 (0)  Connective Tissue Disorders Pain In Extremity 0 (0)  1 (5.0)0 (0) 0 (0)  Neoplasms Benign, 0 (0)  1 (5.0) 0 (0) 0 (0)  Malignant AndUnspecified (Incl Cysts And Polyps) Gastrointestinal 0 (0)  1 (5.0) 0(0) 0 (0)  Stromal Tumour Nervous System   5 (22.7)  1 (5.0)  1 (5.0) 0(0)  Disorders Dizziness   3 (13.6) 0 (0) 0 (0) 0 (0)  Headache  2 (9.1) 1 (5.0)  1 (5.0) 0 (0)  Sinus Headache  1 (4.5) 0 (0) 0 (0) 0 (0) Renal And Urinary 0 (0) 0 (0) 0 (0) 1 (4.8) Disorders Pollakiuria 0 (0)0 (0) 0 (0) 1 (4.8) Skin And 0 (0) 0 (0) 0 (0) 1 (4.8) SubcutaneousTissue Disorders Hyperhidrosis 0 (0) 0 (0) 0 (0) 1 (4.8)

Example 2.3 Discussion

In this study, metformin concentrations in plasma were measured over 11hours at steady-state on the 5th day (FIG. 1) of BID dosing(pre-breakfast and pre-supper) with 1000 mg immediate-release metformin(Metformin IR), 500 mg Metformin DR and 1000 mg Metformin DR, or acombination of 500 mg Metformin IR and 1000 mg Metformin DR. Allsubjects had type 2 diabetes and received each treatment in a randomizedcrossover design with a one week washout between treatments.

The observed profiles indicated lower circulating amounts of metforminwhen using the Metformin DR compared to Metformin IR. The Day 5 pre-doseconcentration of metformin with Metformin IR on the morning of Day 5 was350 ng/mL, which is consistent with steady-state trough concentrationspublished in the literature. After the administration of Metformin IR onthe morning of Day 5, there was a rapid increase in metforminconcentration that peaked 90 min after the dose followed by a steadydecline for the remainder of the sampling period.

With Metformin DR dosing, the highest concentration of metformin wasobserved prior to the dose on the morning of Day 5, which wasapproximately 2 times higher at that time point than those for MetforminIR. Following administration of either dose of Metformin DR, there was adecrease in metformin concentration for the first 240 minutes followedby a small rise in metformin concentration at 360 minutes, whichplateaued for the remainder of the sampling period. The entire 11-hourMetformin DR PK profiles remained below the pre-dose concentrationsmeasured at t=0. These results indicate that the absorption profiles forMetformin DR dosing with the evening meal were slowed relative to dosesadministered with the breakfast meal, consistent with slowed intestinaltransit during the sleeping hours. Thus, concentrations throughout thefirst 240 minutes of the Day 5 profile were predominantly a result ofabsorption from the Day 4 evening dose and concentrations from 240minutes through 660 mins were predominantly a result of absorption fromthe Day 5 morning dose.

Example 3 Analysis of Pharmacokinetic Differences Between Morning andEvening Dosing

To better characterize the pharmacokinetic differences between morningand evening doses, the study of Example 3 was designed to obtain 36-hourPK profiles of Metformin DR at doses of 500 and 1000 mg given at theevening and breakfast meals in healthy subjects. Subjects also received1000 mg Metformin IR with the evening and breakfast meals and 2000 mgmetformin extended-release (Metformin XR) with the evening meal duringseparate treatment periods. All subjects received each treatment in arandomized crossover design with a one week washout between treatments.

The metformin DR formulation was a US-supplied commercially availablefilm-coated immediate-release tablet containing 500 mg metforminhydrochloride, to which additional coatings (a seal coating and anenteric coating) were applied in order to delay release of the drug inthe GI tract until the tablet reaches a pH 6.5 region of the distalsmall intestine. The tablets arc white, biconvex, circular-shaped coatedtablets, each containing 500 mg metformin hydrochloride. Inactiveingredients in the commercially available tablet included povidone,magnesium stearate, hypromellose, and polyethylene glycol. Inactiveingredients in the additional coating systems included hypromellose,triacetin, talc, methacrylic acid copolymer (Eudragit® L30 D-55),poly(methyl acrylate-co-methyl methacrylate-co-methacrylic acid) 7:3:1(Eudragit® FS 30 D), sodium lauryl sulfate, polysorbate 80, glycerylmonostearate, and triethyl citrate. The metformin IR and metformin XRformulations were commercially available formulations (Aurobindo PharmaLimited and Bristol-Myers Squibb respectively) without any modification.

As shown in FIG. 14, both doses of Metformin DR resulted insubstantially less systemic metformin than was observed with eitherMetformin IR or Metformin XR. Of note, the total plasma metforminexposure as measured by AUC of 1000 mg Metformin IR BID and 2000 mgMetformin XR QD (total daily doses of 2000 mg) were very similar,consistent with the previously established bioequivalence between thetwo formulations. The Metformin DR profile over the first 12 hoursshowed that there is a delay in systemic absorption of Metformin DR,with the first quantifiable plasma concentration occurring approximately6-7 hours after the dose. The highest concentration was achievedapproximately 11 hours after the evening dose. After a second dose withMetformin DR in the morning, the plasma concentration of metformindecreased until approximately 15 h post first dose, followed by a smallrise corresponding to approximately 3 hours after the second dose.

As noted above, the data indicate that Metformin IR and both doses ofMetformin DR have slightly greater bioavailability after an evening dosethan the morning dose, perhaps as a result of slower intestinal transitduring the sleeping hours.

Table 18 shows the Mean (CV%) plasma pharmacokinetic parameters ofmetformin following oral administration of each treatment and FIG. 15compares the mean (SEM) values of C_(max) (left panel) and AUC_(0-36 hr)(right panel). Both doses of Metformin DR resulted in substantialreductions in exposure as well as a delay in absorption of 6-7 hours.

TABLE 18 Mean (CV %) Plasma Pharmacokinetic Parameters of MetforminFollowing Oral Administration of Treatment A, B, C, and D - EvaluablePopulation 1000 mg Met IR 500 mg Met DR 1000 mg Met DR 2000 mg Met XRBID BID BID QD PK Parameters (Treatment A) (Treatment B) (Treatment C)(Treatment D) N 19 19 19 19 AUC₀₋₂₄ (ng*h/mL) 17361 (24.3) 5541(31.9)     7634 (31.9)     16406 (24.5) AUC_(0-t) (ng*h/mL) 18709 (24.3)6164 (32.9)     9014 (29.5)     16989 (24.8) AUC_(0-∞) (ng*h/mL) 19423(23.6) 6690 (30.4)^(b )   10277 (25.6)^(b )    17398 (24.7) C_(max)(ng/mL)  1328 (20.6) 607 (24.0)   905 (26.8)    1688 (25.0) t_(max) ^(a)(h)    15.0 (4.00, 16.0) 11.0 (6.02, 19.0) 11.0 (7.00, 19.0)    7.05(6.00, 11.0) t_(lag) ^(a) (h)      0.00 (0.00, 0.500) 6.02 (1.50, 10.0)7.00 (3.00, 8.00)    0.00 (0.00, 2.00) t_(1/2) (h)  8.26 (31.0) 6.19(49.4)^(b  )  11.2 (39.9)^(b  )   6.09 (45.5) ^(a)median (min, max)^(b)n = 18 ^(c)n = 17

Geometric LSM ratios and 90% confidence intervals for the ln-transformedC_(max), AUC_(0-t), and AUC_(0-∞) from the Metformin DR treatments (500mg BID [Treatment B] and 1000 mg BID [Treatment C]) relative to theMetformin IR (1000 mg BID [Treatment A]) are shown in Table 19 and therelative bioavailability is plotted in the left panel of FIG. 16. Theseresults indicate that the rate and extent of exposure (C_(max),AUC_(0-t) and AUC_(0-∞)) from 500 mg BID Metformin DR were approximately55%, 68% and 67% lower, respectively, than those from 1000 mg BIDMetformin IR. At 1000 mg BID Metformin DR (Treatment C, total daily doseof 2000 mg metformin) the rate and extent of exposure (C_(max),AUC_(0-t) and AUC_(0-∞)) were approximately 33%, 52% and 47% lower,respectively, than those from 1000 mg BID Metformin IR (Treatment A,total daily dose of 2000 mg metformin). Similar reductions in the rateand extent of exposure were observed when 500 mg BID and 1000 mg BID ofMetformin DR were compared to 2000 mg QD of Metformin XR (Table 20; FIG.16, right panel).

TABLE 19 Relative Bioavailability of Metformin Following OralAdministration of 500 mg BID and 1000 mg BID Metformin DR Treatmentcompared to 1000 mg BID Metformin IR- Evaluable Population GeometricLeast-Square % Ratio of LSmeans PK Means (90% CI) p-value Parameter A BC B/A C/A B/A C/A AUC_(0-t) 18116 5816 8611 32.1 47.5 SS SS (ng*h/mL)(29.30-35.18) (43.38-52.09) AUC_(0-∞) 19981 6644 10586 33.3 53.0 SS SS(ng*h/mL) (30.37-36.40) (48.36-58.05) C_(max) 1294 586 865 45.3 66.8 SSSS (ng/mL) (40.88-50.13) (60.34-74.00) SS: Statistically significant(p-value < 0.0001) Treatment A: 1000 mg Metformin IR BID (2 × 500 mgmetformin HCl tablets [immediate-release]) Treatment B: 500 mg MetforminDR BID (1 × 500 mg metformin HCl tablet [delayed-release pH 6.5enteric-coated]) Treatment C: 1000 mg Metformin DR BID (2 × 500 mgmetformin HCl tablets [delayed-release pH 6.5 enteric-coated])

TABLE 20 Relative Bioavailability of Metformin Following OralAdministration of 500 mg BID and 1000 mg BID Metformin DR Treatmentcompared to 2000 mg QD Metformin XR - Evaluable Population GeometricLeast-Square % Ratio of LSmeans PK Means (90% CI) p-value Parameter B CD B/D C/D B/D C/D AUC_(0-t) 5816 8611 16450 35.4 52.3 SS SS (ng*h/mL)(32.27-38.74) (47.77-57.36) AUC_(0-∞) 6644 10586 17873 37.2 59.2 SS SS(ng*h/mL) (33.93-40.73) (54.10-64.84) C_(max) 586 865 1631 35.9 53.0 SSSS (ng/mL) (32.43-39.77) (47.88-58.71) SS: Statistically significant(p-value < 0.0001) Treatment B: 500 mg Metformin DR BID (1 × 500 mgmetformin HCl tablet [delayed-release pH 6.5 enteric-coated]) TreatmentC: 1000 mg Metformin DR BID (2 × 500 mg metformin HCl tablets[delayed-release pH 6.5 enteric-coated]) Treatment D: 2000 mg MetforminXR QD (4 × 500 mg metformin HCl tablets [extended-release])

Taken together, the pharmacokinetic results of Examples 2 and 3 indicatethat delivery of metformin to the lower bowel by administering MetforminDR reduces 24 hour bioavailability by approximately 50% relative toMetformin IR and Metformin XR at the same daily dose. Greater reductionsin exposure were observed when the Metformin DR dose was reduced from atotal daily dose of 2000 mg to 1000 mg, without a reduction in efficacy.In addition, the time of Metfoimin DR dosing (with the morning orevening meals) meaningfully affected the timing of metformin release inthe intestine (3 vs. 6-7 hours post-dose, respectively) and provides anexplanation for the observation from the study in Example 2 that, theMetformin DR trough values observed prior to the morning dose werehigher than the trough values observed 12 hours after the morning dose.The significance of QD am dosing was confirmed in a subsequent studyevaluating 1000 mg metformin DR QD with the morning and evening meal incomparison with 500 mg metformin DR bid in twelve type II diabeticpatients. As shown in FIGS. 17A and B QD am dosing showed the lowestoverall exposure of metformin with a trend toward the largest effect onfasting glucose in comparison with QD pm and bid dosing.

In the Example 2 study, while the systemic exposure to metformin wassubstantially reduced with Metformin DR (45% with 2000 mg/day and ˜60%with 1000 mg/day, relative to 2000 mg/day of Metformin IR), the fullglucose lowering effects of Metformin IR (2000 mg/day) were maintained.Given that the full glucose lowering effect was observed at both 2000 mgand 1000 mg daily of Metformin DR, lower doses are viable, allowing formore elegant dosage forms than are currently available with existingproducts (Metformin IR and Metformin XR (i.e., smaller tablets, fullyeffective fixed dose combinations, once daily dosing). Moreover, unlikeMetformin IR, Metformin DR was not associated with any nausea andvomiting at either dose.

Example 4 A 12-Week, Randomized, Double-Blind, Placebo-Controlled,Parallel-Group, Multicenter Study to Assess the Efficacy, Safety, andTolerability of Delayed-Release Metformin in Subjects with Type 2Diabetes Mellitus

This study will compare the effect of delayed-release metformin (Met DR)to placebo on glycemic control as assessed by fasting plasma glucosewhen administered for 4 weeks in subjects with type 2 diabetes mellitus(T2DM), and will further assess the safety and tolerability of a rangeof doses of Met DR administered for 4 weeks in subjects with T2DM.

The study will also compare the effect of Met DR to placebo on glycemiccontrol as assessed by HbA1c and fasting plasma glucose whenadministered for 12 weeks in subjects with T2DM. Assess the safety andtolerability of a range of doses of Met DR when administered for 12weeks in subjects with T2DM. It will also assess the dose-dependenteffect of Met DR on HbA1c and fasting plasma glucose when administeredfor 4 and 12 weeks in subjects with T2DM, and compare the effects of MetDR, extended-release metformin (Met XR), and placebo administered for 4and 12 weeks in subjects with T2DM on the following:

-   -   Change from baseline in fasting plasma glucose over time    -   Change from baseline in HbA1c over time    -   Change from baseline in body weight over time

Study Design

Protocol LCRM105 is a Phase 2, randomized, double-blind, multicenter,placebo-controlled, six-arm study. There are 8 study visits; onescreening visit (Visit 1) followed by 7 randomized treatment periodvisits (Visits 2 through 8). Subjects on metformin and/or dipeptidylpeptidase-4 (DPP-4) inhibitors are to discontinue use of thesemedications for at least 14 days and no more than 17 days prior torandomization at Visit 2. At Visit 2, each of approximately 240 subjectswill be randomized to one of 6 treatment groups in the proportion of1:1:1:1:1:1. Treatments A, B, C and D will be administered once daily(QD) in the morning (AM) and will be blinded. Treatments E and F will beadministered QD in the evening (PM) and will not be blinded.Randomization is to be stratified by Visit 1 (Screening) HbA1c (<8% vs.≧8%).

Treatment Groups for the study are shown in Table 21 below:

TABLE 21 Treatment Groups for Study LCRM105 Group N Treatment A 40Placebo QD AM B 40 Met DR 600 mg QD AM C 40 Met DR 800 mg QD AM D 40 MetDR 1000 mg QD AM E 40 Met XR 1000 mg QD PM F 40 Met XR 2000 mg QD PM**Met XR 2000 mg QD PM arm will initiate at Met XR 1000 mg QD for 1 week,then titrate to 1500 mg QD for 1 week, before increasing to 2000 mg QDfor the remainder of the study

At randomized treatment period visits (Visits 2, 3, 4, 5, 6, 7, and 8)subjects are to be instructed to arrive at the study clinic after havingfasted overnight for at least 10 hours. Subjects randomized to QD AMdosing regimens are to be instructed to withhold the morning dose ofstudy medication on the days of study visits until after the fastingblood draws are completed. The morning dose is to be administered at thestudy site on the days of study visits (Visits 2 through 7 only).Physical examination and electrocardiogram (ECG) are to be assessed atVisit 8. Body weight and vital signs are to be measured at Visits 2through 8. Samples for clinical chemistry, hematology and urinalysis areto be collected at Visits 2, 4, 6, 7 and 8. HbA1c is to be measured atVisits 2, 6, 7 and 8. Fasting blood samples will be collected formeasurement of plasma glucose, metformin pharmacokinetics (PK), insulin,PYY, and GLP-1 at Visits 2 through 8. Adverse events are to be assessedat Visits 2 through 8. Review of study medication dosing compliance isto be performed at Visits 3 through 8

If a subject's underlying diabetes is inadequately controlled during thestudy and if the subject is experiencing hyperglycemia that is asignificant worsening from the baseline condition, resulting in a lossof glucose control, the subject is to be withdrawn from the study basedon the investigator's clinical judgment, guided by appropriate criteria.The investigator may contact the medical monitor to discuss appropriateclinical management as well as the continued participation of subjectsexperiencing hyperglycemia.

Study Duration

-   -   Total study duration may be between 83 to 107 days depending on        the number of intervening days between study visits

Study Population

Males and females, 18 to 65 years old at Visit 1 (Screening) with a bodymass index 25.0 to 45.0 kg/m2 (inclusive). Approximately 240 subjectswith type 2 diabetes mellitus treated with diet and exercise alone,metformin alone, DPP-4 inhibitor alone, or a combination regimen ofmetformin with a DPP-4 inhibitor only at Visit 1 (Screening). Subjectstreated with a DPP-4 inhibitor or metformin are to discontinue use ofany DPP-4 inhibitors or prescribed metformin for 14 to 17 days prior toenrollment and throughout the study. HbA1c of 7.0 to 9.5% (inclusive) atVisit 1 (Screening) if treated with diet and exercise alone or 6.0 to9.5% (inclusive) at Visit 1 (Screening) if treated with metformin alone,DPP-4 inhibitor alone, or a combination regimen of metformin with aDPP-4 inhibitor. Serum creatinine <1.5 mg/dL (male) or <1.4 mg/dL(female) and estimated glomerular filtration rate (eGFR) ≧60 mL/min/1.73m2 prior to randomization.

Study Medication

-   -   Placebo (EFP0079)    -   Met DR (EFB0080): 500 mg metformin HC1 delayed-release tablets        (with a pH 6.5 enteric coating)    -   Met DR (EFB0081): 300 mg metformin HC1 delayed-release tablets        (with a pH 6.5 enteric coating)    -   Met XR: 500 mg metformin HCl extended-release tablets        (Glucophage® XR)

Study Methods

Randomized treatment is to be administered QD before the morning meal(Treatments A, B, C and D) or QD before the evening meal (Treatments Eand F) over 84 days. Fasting plasma glucose, HbAl c, body weight,metformin PK, insulin, PYY, and GLP-1 are to be collected at scheduledtime points

Efficacy Assessments

-   -   Fasting plasma glucose    -   HbA1c    -   Body weight

Pharmacokinetic Assessments

-   -   Plasma metformin

Pharmacodynamic Assessments

-   -   Insulin    -   PYY    -   GLP-1

Safety Assessments

-   -   Adverse events    -   Electrocardiogram    -   Physical exam    -   Vital signs    -   Clinical chemistry, hematology, and urinalysis

All patents and patent publications referred to herein are herebyincorporated by reference.

Certain modifications and improvements will occur to those skilled inthe art upon a reading of the foregoing description. It should beunderstood that all such modifications and improvements have beendeleted herein for the sake of conciseness and readability but areproperly within the scope of the following claims.

What is claimed is:
 1. A fixed-dose combination dosage form for reducingcardiometabolic risk in patients in need thereof comprising at least onebiguanide compound, at least one statin and at least one additionalactive agent.
 2. The combination dosage form according to claim 1,wherein said at least one additional active agent is selected from thegroup consisting of anti-hypertensives, anti-platelet agents, diuretics,bile acid sequesterants, incretin mimetics and enhancers, anti-obesityagents, oral anti-diabetic agents, and anti-atherosclerotics.
 3. Thecombination dosage form according to claim 1 or 2, comprising at leasttwo, three, or four additional active agents.
 4. The combination dosageform according to claim 1, comprising less than 950, 900 or 850 mg ofmetformin or other biguanide
 5. The combination dosage form according toclaim 1, comprising from about 300 mg to about 900 mg of metformin, morepreferably from about 400 mg to about 800 mg of metformin.
 6. Thecombination dosage form according to claim 6, wherein said oralanti-diabetic agent is selected from the group consisting ofsulfonylureas, nonsulfonylureas, thiazolidinediones, dual PPAR agonists,dipcptidyl peptidase-4 inhibitors, SGLT1 or SGLT2 inhibitors,mcglitinidcs, alpha-glucosidase inhibitors, agonists of GPR40, GPR120,GPR119, GPR41, and GPR43
 7. The combination dosage form according toclaim 2, wherein said antihypertensive is selected from the groupconsisting of beta blockers, alpha blockers, mixed alpha/beta blockers,calcium channel blockers such as dihydropyridines andnon-dihydropyridines, renin inhibitors, ACE inhibitors, and angiotensinII receptor antagonists.
 8. The combination dosage form according toclaim 2, wherein said anti-platelet medication is selected from thegroup consisting of cyclooxygenase inhibitors, ADP receptor inhibitors,phosphodiesterase inhibitors, adenose reuptake inhibitors, thromboxanesynthase or receptor inhibitors, anagrelide, prasugrel, and cloricromen.9. The combination dosage form according to claim 2, wherein saiddiuretic is selected from the group consisting of loop diuretics,thiazide diuretics, thiazide-like diuretics, and potassium-sparingdiuretics.
 10. The combination dosage form according to claim 2, whereinthe metformin or other biguanide compound is targeted for delivery tothe small intestine, and the formulation comprises an oral dosage formenterically coated at a pH at or above 5.0 or 5.5.
 11. The combinationdosage form according to claim 1, wherein the biguanide compound istargeted for delivery to the distal small intestine, and the formulationcomprises an oral dosage form enterically coated at a pH at or above 6.0or 6.5.
 12. The combination dosage form according to claim 1, whereinsaid combination dosage form comprises metformin, at least one statin,at least one anti-hypertensive and optionally at least one anti-plateletmedication.
 13. The combination dosage for according to claim 12,wherein said anti-hypertensive comprises an ACE inhibitor or anangiotensin II receptor antagonist.
 14. The combination dosage formaccording to claim 12, comprising from about 600-800 mg of metformin,from about 20-40 mg of simvastatin or atorvastatin, from about 20-25 mgof benazepril, lisinopril or losartan, and from about 75-90 mg ofaspirin.
 15. A method of reducing cardiometabolic risk in a patient inneed thereof, comprising administering a combination dosage formaccording to any one of claims 1-13 to said patient.
 16. The methodaccording to claim 15, wherein reducing cardiometabolic risk comprisestreating an underlying metabolic disorder in said patient.
 17. Themethod according to claim 15, wherein reducing cardiometabolic riskcomprises treating cardiovascular disease in said patient.
 18. Themethod according to claim 15, wherein said combination dosage form isadministered to said patient once daily.
 19. The method according toclaim 18, wherein said combination dosage form is administered to saidpatient once daily in the morning.